NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.
Question 2 of 5
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring close monitoring.
Question 3 of 5
The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced?
Correct Answer: C
Rationale: The description of the seizure, with the entire body becoming rigid (tonic phase) followed by alternating relaxation and contraction of muscles in all four extremities (clonic phase), is characteristic of a tonic-clonic seizure. Partial seizures involve only a portion of the body or brain, absence seizures are brief lapses in awareness without significant motor activity, and complex partial seizures involve altered consciousness with automatisms, none of which match the described symptoms.
Question 4 of 5
The nurse is caring for a client with a history of chronic bronchitis who is prescribed theophylline (Theo-Dur). Which of the following symptoms indicates theophylline toxicity?
Correct Answer: B
Rationale: Tachycardia is a sign of theophylline toxicity, indicating the need for immediate medical evaluation.
Question 5 of 5
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds.
Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.