NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to administer a dose of lorazepam (Ativan) for anxiety. Which assessment is most important before administration?
Correct Answer: B
Rationale: Lorazepam, a benzodiazepine, can cause respiratory depression, so assessing respiratory rate is critical before administration. Other vital signs are monitored but are less specific.
Question 2 of 5
The nurse is caring for a client following cast application for a fractured ulna. Which finding should be reported to the doctor?
Correct Answer: D
Rationale: Paresthesia (numbness or tingling) in the fingers suggests nerve compression or compromised circulation possibly from a tight cast and requires immediate reporting. Pain is expected and warm fingers with a pulse are normal findings.
Question 3 of 5
A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:
Correct Answer: D
Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
Question 4 of 5
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:
Correct Answer: A
Rationale: This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. This answer is incorrect. The client should continue the medication until the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.
Question 5 of 5
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
Correct Answer: D
Rationale: When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L.