NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a postoperative client when the client becomes nonresponsive and pale,with a BP of 90/40. The nurse recognizes that the necessary intervention at this time is to:
Correct Answer: B
Rationale: Hypotension (BP 90/40) pallor,and nonresponsiveness suggest hypovolemic shock likely from postoperative bleeding. Increasing the IV infusion rate (e.g. saline) restores volume. Trendelenburg is controversial atropine treats bradycardia,and the emergency cart is secondary to immediate fluid resuscitation.
Question 2 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 3 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 4 of 5
A client with a diagnosis of Amyotrophic Lateral Sclerosis (ALS) has been prescribed riluzole (Rilutek). Which does the nurse include when teaching the client about this drug?
Correct Answer: A, C, D, E
Rationale: Riluzole teaching includes avoiding alcohol (
A), reporting fever (
C), consistent timing (
D), and regular lab monitoring (E). Taking with food (
B) is not required.
Question 5 of 5
A client with a history of lymphoma is admitted with complaints of night sweats. The nurse should expect the client to have:
Correct Answer: A
Rationale: Night sweats are a B symptom of lymphoma, along with fever and weight loss, indicating systemic disease.