NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 2 of 5
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
Correct Answer: A
Rationale: Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. Most antipsychotic drugs are chemically similar and will produce the same side effects.
Question 3 of 5
A client with a history of pneumonia is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Dyspnea in pneumonia indicates impaired gas exchange, so administering oxygen is the priority to improve oxygenation.
Question 4 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
Question 5 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.