NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
Question 2 of 5
The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
Correct Answer: C
Rationale: Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression.
Question 3 of 5
The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the I.V. pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. Which of the following is not appropriate to do by the nurse when recognizing that the previous dose was not administered 8 hours ago to the client with pneumonia?
Correct Answer: A
Rationale: Discarding the medication without investigation is inappropriate; the nurse should verify, document, and address the error appropriately.
Question 4 of 5
A client with a history of peptic ulcer disease is prescribed misoprostol (Cytotec). The nurse should instruct the client to:
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal upset and protect the stomach lining.
Question 5 of 5
The nurse caring for a child diagnosed with a patent ductus arteriosus should base planning on which fact concerning this disorder?
Correct Answer: D
Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. The remaining options are not characteristics of this cardiac defect.