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Questions 158

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NCLEX RN Nursing Exam Questions

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Question 1 of 5

The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

Correct Answer: D

Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.

Question 2 of 5

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

Correct Answer: A

Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.

Question 3 of 5

Which of the following statements applies to the care of the client hospitalized with influenza?

Question Image

Correct Answer: B, C, E

Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (
B), keeping equipment in the room (
C), and wearing a mask for direct care (E). N-95 masks (
A) are for airborne diseases (e.g., T
B). The door should remain closed (
D) to limit droplet spread.

Question 4 of 5

On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:

Correct Answer: C

Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order.
To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.

Question 5 of 5

A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn't that a lot?' The nurse's best response is:

Correct Answer: C

Rationale: The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communication with the husband to identify underlying fears and knowledge deficits.

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