NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
What would be the most appropriate follow-up by the home care nurse for a 57-year-old male client with a hemoglobin of 10 g/dl and a hematocrit of 32%?
Correct Answer: A
Rationale: The correct answer is to ask the client if he has noticed any bleeding or dark stools. Normal hemoglobin for males is 13.0 - 18 g/dl, and normal hematocrit for males is 42 - 52%. The values of hemoglobin and hematocrit provided for the client are below normal, indicating mild anemia. The first step for the nurse is to inquire about any signs of bleeding or changes in stools that could suggest bleeding from the gastrointestinal tract. This helps in assessing the possible cause of the low hemoglobin and hematocrit levels. The other options are not appropriate as calling 911 and going to the emergency department immediately is not warranted for mild anemia, scheduling a repeat test in 1 month delays addressing the current concern, and referring the client to a hematologist may be premature without investigating the cause of the low levels first.
Question 2 of 5
A patient has been taking mood stabilizing medication but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?
Correct Answer: D
Rationale: The correct answer is Risperidone (Risperdal) because it is the only medication among the options that does not require regular lab testing. Risperidone is not associated with the need for routine blood draws to monitor medication levels or potential side effects.
Choices A, B, and C (Valproic Acid, Clozapine, Lithium) are all known to require frequent lab monitoring due to various reasons such as potential toxicity, therapeutic drug levels, or adverse effects on certain organ functions.
Therefore, considering the patient's fear of needles and the desire to avoid frequent blood tests, Risperidone would be the most suitable option.
Question 3 of 5
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
Correct Answer: C
Rationale: In the scenario of persistent vomiting, the child is at risk of developing metabolic alkalosis due to the loss of hydrochloric acid. Vomiting leads to the loss of gastric acid, resulting in an imbalance that causes metabolic alkalosis. Metabolic acidosis is incorrect as it would occur in a child with diarrhea due to the loss of bicarbonate. While diarrhea can sometimes be associated with vomiting, in this case, the primary focus is on the effects of vomiting. Hyperactive bowel sounds are not typically associated with vomiting, making this choice less relevant to the situation described.
Question 4 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 5 of 5
When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?
Correct Answer: B
Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (
Choice
A) is not a typical symptom of pyloric stenosis. Increased urine output (
Choice
C) is not directly associated with this condition. Vomiting large amounts of bile (
Choice
D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.