NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
Correct Answer: B
Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.
Question 2 of 5
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
Correct Answer: A
Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (
Choice
B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (
Choice
C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (
Choice
D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.
Question 3 of 5
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
Correct Answer: C
Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.
Question 4 of 5
A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
Correct Answer: A
Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice
B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice
C) is not the most probable cause given the history provided. Metabolic alkalosis (choice
D) is not associated with sudden seizing in this context.
Question 5 of 5
The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
Correct Answer: C
Rationale: The correct answer is nephrotoxicity. Calcium disodium edetate, used in chelation therapy for lead poisoning, can lead to kidney toxicity. This is an important side effect to monitor in patients undergoing this treatment.
Choices A, B, and D are incorrect. Neurotoxicity, hepatomegaly, and ototoxicity are not typically associated with calcium disodium edetate therapy for lead poisoning.