NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of atrial fibrillation. Which finding requires immediate intervention?
Correct Answer: C
Rationale: Dizziness and syncope in atrial fibrillation suggest hemodynamic instability, possibly from rapid ventricular response, requiring immediate intervention. Mild tachycardia, normal BP, and saturation are less urgent.
Question 2 of 5
The nurse is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.
Question 3 of 5
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:
Correct Answer: A
Rationale: Tardive dyskinesia is a common side effect of antipsychotic medications such as haloperidol. Discontinuing the medication can alleviate symptoms. Although mild tremors are an early sign of Parkinson's disease, haloperidol must be discontinued first and the client further evaluated. These symptoms do not necessarily indicate a more advanced stage of Alzheimer's disease. Most antipsychotic drugs are chemically similar and will produce the same side effects.
Question 4 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 5 of 5
A client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
Correct Answer: C
Rationale: Stomahesive is a skin barrier used to protect peristomal skin from irritation due to ileostomy output. Karaya powder is less common, daily irrigation is not needed for ileostomies, and stool softeners are irrelevant as output is liquid.