NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
Correct Answer: A
Rationale: Improved muscle strength after edrophonium indicates myasthenic crisis, not cholinergic crisis, which involves excessive anticholinesterase effects.
Question 2 of 5
A client receiving chemotherapy has a platelet count of 15,000 mm³ (15 x 10â¹/L). Based on this laboratory result, which form of precautions should the nurse implement?
Correct Answer: B
Rationale: When the platelet count is less than 20,000 mm³ (20 x 10â¹/L), the client is at risk for bleeding, and the nurse should institute bleeding precautions. Contact precautions are initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. Neutropenic precautions would be instituted for a client with a low neutrophil count.
Question 3 of 5
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
Question 4 of 5
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
Question 5 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.