NCLEX Questions, NCLEX-PN Practice Questions Quizlet Questions, NCLEX-PN Questions, Nurselytic

Questions 227

NCLEX-PN

NCLEX-PN Test Bank

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Question 1 of 5

The morning staff of an inpatient psychiatric unit has just completed the change of shift report. The nurse should give priority to assessing the client:

Correct Answer: C

Rationale: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and indicates potential toxicity, requiring immediate assessment. Answer A is important but less urgent unless the hallucinations are commanding harm. Answer B is incorrect as the client is only scheduled for therapy, not in immediate danger. Answer D is within normal WBC range and less critical.

Question 2 of 5

A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?

Correct Answer: A

Rationale: These side effects are common and should subside in a few days. Nausea, metallic taste, and fine hand tremors are common side effects that usually subside quickly.

Question 3 of 5

The nurse is caring for a dark-skinned client hospitalized with hepatitis. The nurse can best observe the presence of jaundice in the client by assessing the client's:

Correct Answer: C

Rationale: The sclera is the most reliable site to assess jaundice in dark-skinned clients, as bilirubin deposition is visible in the whites of the eyes.

Question 4 of 5

The nurse is caring for a client with a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. The nurse should

Correct Answer: A

Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the system (e.g., loose connections or lung leak), requiring assessment to locate and correct it. Increasing suction (
B) won’t fix the leak, clamping (
C) is dangerous, and notifying the physician (
D) follows assessment.

Question 5 of 5

A patient with schizophrenia is prescribed risperidone (Risperdal). Which of the following side effects should the nurse monitor for?

Correct Answer: C

Rationale: Risperidone, an antipsychotic, commonly causes extrapyramidal symptoms (e.g., tremors, rigidity), requiring monitoring. Weight gain, not loss, is typical, and hyperactivity or insomnia are less common.

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