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
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
Correct Answer: B
Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the client's formulation of a plan for the suicide attempt. Although all of the choices are correct, preventing self-harm is the priority in the context of the suicidal client. Clients with a history of self-harm are greater suicide risks.
Question 3 of 5
A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.
Question 4 of 5
The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?
Correct Answer: C
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. The remaining options are unrelated to the assessment findings of rheumatic fever.
Question 5 of 5
A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.