NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 2 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 3 of 5
The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:
Correct Answer: D
Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
Question 4 of 5
The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
Correct Answer: D
Rationale: Quinidine, an antiarrhythmic, can prolong the QT interval, increasing the risk of torsades de pointes. Monitoring the ECG for QT prolongation is critical. The other ECG changes are not specific to quinidine.
Question 5 of 5
A dose of theophylline may need to be altered if a client with COPD:
Correct Answer: D
Rationale: The effects of morphine or an allergic response to the drug will not affect theophylline clearance. Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.