NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.
Question 2 of 5
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (
A) to keep oil against the retina, head bowed when upright (
D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (
B) is not strict, and diet (
C) progresses as tolerated.
Question 3 of 5
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (
B), nausea (
C), and hyperactivity (
D) are not associated with clopidogrel.
Question 4 of 5
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
Question 5 of 5
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
Correct Answer: B
Rationale: Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. This statement is true. These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.