NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
Question 2 of 5
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
Correct Answer: A
Rationale: Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. This action is of lesser importance at this time. Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. Once the victim enters the emergency room, it is important not to leave her alone.
Question 3 of 5
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.
Question 4 of 5
Hematotympanum and otorrhea are associated with which of the following head injuries?
Correct Answer: A
Rationale: Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms.
Question 5 of 5
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.