NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 of 5
The nurse is preparing to administer blood to a client with anemia. Which signs and symptoms of transfusion reaction should the nurse monitor for during the first 30 minutes? Select all that apply.
Correct Answer: B, D, E
Rationale: Sudden hypertension, restlessness, confusion, jugular vein distension, low back pain, and impending doom indicate possible transfusion reactions (e.g., hemolytic or circulatory overload). Normal respiratory rate and oxygen saturation are not concerning.
Question 2 of 5
A client with a history of depression is treated with Parnate (tranylcypromine), an MAO inhibitor. Ingestion of foods containing tyramine while taking an MAO inhibitor can result in:
Correct Answer: A
Rationale: Tyramine-rich foods can cause a hypertensive crisis in clients on MAO inhibitors due to the inability to metabolize tyramine, leading to norepinephrine release.
Question 3 of 5
A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, 'I don't know why you are all so worried; I am in control. I don't have a problem.' Which defense mechanism is being utilized?
Correct Answer: D
Rationale: Denial is the defense mechanism where the client refuses to acknowledge the reality of their substance abuse problem, minimizing its severity.
Question 4 of 5
The nurse is assessing a client with suspected myasthenia gravis. Which of the following findings would the nurse expect?
Correct Answer: B
Rationale: ptosis and diplopia are common signs of myasthenia gravis due to muscle weakness in the eyes
Question 5 of 5
The nurse is admitting a client with acute liver failure. According to the Patient's Bill of Rights, which responsibilities does the nurse understand to be the client's duty? Select all that apply.
Correct Answer: A, D, E
Rationale: Clients are responsible for providing translators, accepting consequences of refusing treatment, and giving accurate medical history. Emergency stabilization is a provider duty, and payment proof is not required before care.