NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a spinal cord injury who is experiencing autonomic dysreflexia. The nurse should:
Correct Answer: C
Rationale: Autonomic dysreflexia is often triggered by bladder distension. Inserting a Foley catheter relieves the trigger. Vasodilators and positioning are secondary, and prone position is unsafe.
Question 2 of 5
The client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which potential side effect?
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia by reducing potassium excretion. Hypokalemia is caused by other diuretics, hypoglycemia is unrelated, and spironolactone lowers blood pressure.
Question 3 of 5
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:
Correct Answer: C
Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.
Question 4 of 5
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
Correct Answer: C
Rationale: St. John's wort increases photosensitivity, so sunscreen use may paradoxically increase skin reactions; clients should be cautioned about sun exposure.
Question 5 of 5
A client is being admitted with syndrome of inappropriate diuretic hormone. Which does the nurse expect to observe?
Correct Answer: B,D,E
Rationale: SIADH causes water retention, leading to hyponatremia, which can cause tachycardia (
B), hostility (
D), and muscle weakness (E). Increased thirst (
A) and polyuria (
C) are more associated with diabetes insipidus.