NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of multiple sclerosis. Which intervention is most appropriate to prevent complications?
Correct Answer: C
Rationale: Hot baths can exacerbate multiple sclerosis symptoms by increasing body temperature, causing fatigue or weakness. Weight-bearing exercise is encouraged, antibiotics are not routine, and fluid restriction is harmful.
Question 2 of 5
An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis?
Correct Answer: D
Rationale: There is no evidence of pain in infants with pyloric stenosis whether eating or not. There are both good appetite and feeding habits in these children. Because of regurgitation, there is usually decreased frequency and quantity of stools and also signs of dehydration and weight loss. Along with upper abdominal distention, there is a characteristic palpable olive-shaped mass located to the right of the umbilicus.
Question 3 of 5
The nurse is caring for a client with a history of a ventricular septal defect. Which finding should be reported to the doctor immediately?
Correct Answer: D
Rationale: Cyanosis in a ventricular septal defect indicates significant shunting and hypoxemia, a critical finding requiring immediate reporting. Murmurs, tachycardia, and fatigue are expected but less urgent.
Question 4 of 5
A client with a history of a stroke is receiving tPA (alteplase). The nurse should:
Correct Answer: A
Rationale: tPA, a thrombolytic, increases bleeding risk, requiring close monitoring for signs like hematuria or hematoma. It’s given over 1 hour, glucose is unrelated, and fluids are not restricted.
Question 5 of 5
A client with a history of a burn injury is receiving Silvadene (silver sulfadiazine). The nurse should monitor the client for:
Correct Answer: A
Rationale: Silver sulfadiazine can cause neutropenia, requiring monitoring of white blood cell counts. Hyperkalemia, hypoglycemia, and hypertension are not typical side effects.