NCLEX-RN
Free NCLEX RN Exam Questions
Question 1 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which finding would require the nurse to withhold the dose?
Correct Answer: A
Rationale: Digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as bradycardia increases the risk of toxicity. The other findings are within normal ranges for digoxin administration.
Question 2 of 5
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
Question 3 of 5
Which of the following blood gas parameters primarily reflects respiratory function?
Correct Answer: A
Rationale: The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function.
Question 4 of 5
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
Question 5 of 5
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
Correct Answer: C
Rationale: The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis.
To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.