NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?
Correct Answer: B
Rationale: Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.
Question 2 of 5
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
Question 3 of 5
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
Question 4 of 5
What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.
Question 5 of 5
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.