NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The client is receiving a continuous infusion of insulin for diabetic ketoacidosis. Which laboratory value should the nurse monitor most closely?
Correct Answer: A
Rationale: Insulin therapy in diabetic ketoacidosis shifts potassium into cells, risking hypokalemia, which can cause arrhythmias. Sodium, BUN, and A1C are monitored but are less critical during acute treatment.
Question 2 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 3 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: A
Rationale: High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C,
D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
Question 4 of 5
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?
Correct Answer: B
Rationale: A Foley catheter is inserted during cervical radiation implants to keep the bladder empty, reducing radiation exposure. TV/phone use (
A) is allowed, high-fiber diet (
C) is not specific, and excretions (
D) are not radioactive with internal implants.
Question 5 of 5
A client has an order to administer cisplatin (Platinol). Which drug would the nurse expect to be ordered to reduce renal toxicity from the cisplatin infusion?
Correct Answer: A
Rationale: Amifostine protects kidneys from cisplatin’s nephrotoxicity by neutralizing free radicals. Dexrazoxane (
B) protects the heart, Mesna (
C) prevents bladder toxicity, and Pamidronate (
D) treats hypercalcemia.