NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.
Question 2 of 5
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
Question 3 of 5
The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
Question 4 of 5
The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
Question 5 of 5
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.