NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
Question 2 of 5
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.
Question 3 of 5
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
Correct Answer: C
Rationale: Filing an incident report addresses the improper disposal of a medication, ensuring investigation and prevention of future errors.
Question 4 of 5
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.
Question 5 of 5
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.