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NCLEX RN High-Yield Questions Questions

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Question 1 of 5

The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin). Which of the following findings would indicate digoxin toxicity?

Correct Answer: A

Rationale: Blurred vision is a classic sign of digoxin toxicity, along with nausea, confusion, and arrhythmias, due to excessive drug levels affecting the nervous system.

Question 2 of 5

The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin). Which of the following findings would indicate digoxin toxicity?

Correct Answer: A

Rationale: Blurred vision is a classic sign of digoxin toxicity, along with nausea, confusion, and arrhythmias, due to excessive drug levels affecting the nervous system.

Question 3 of 5

A client has been prescribed lansoprazole for 4 weeks. The nurse should monitor the client for relief from which problem?

Correct Answer: B

Rationale: Lansoprazole is a proton pump inhibitor and is classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often referred to as heartburn by clients. The medication does not improve the other symptoms listed.

Question 4 of 5

A nurse is administering I.V. fluids to a dehydrated client. When administering an I.V. solution of 3% sodium chloride, what should the nurse do? Select all that apply.

Correct Answer: A,B,C

Rationale: 3% sodium chloride is hypertonic and requires monitoring of intake/output, jugular veins for fluid overload, and neurologic status for hypernatremia effects. Forcing fluids or catheterization is not indicated.

Question 5 of 5

A multiparous client 48 hours postpartum who is breast-feeding tells the nurse, 'I'm having a lot of cramping. This didn't happen when I nursed my first baby,' which of the following would be the nurse's best response?

Correct Answer: D

Rationale: Breast-feeding stimulates oxytocin release, causing uterine contractions and cramping, which is normal and often more noticeable in multiparous women.

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The nurse is planning to complete the following assessments during the last half hour of the shift. Which of the following assessments has the highest priority and should be accomplished first?
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
A client with a history of alcohol abuse is admitted with confusion and tremors. The nurse should prepare to administer which medication?
The nurse is developing a plan of care for a client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse should document which goals for the client in the plan of care? Select all that apply.

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