NCLEX RN· Full Length · NCLEX RN Test Bank Questions PDF
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Showing all 10 practice questions with expert explanatory rationales.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
Expert Explanatory Rationale
Correct Answer: An exaggerated sense of well-being.
Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should monitor the client for which of the following adverse effects?
Expert Explanatory Rationale
Correct Answer: Bleeding.
Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring.
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
Expert Explanatory Rationale
Correct Answer: Assess the client's mental status regularly.
Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.
A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
Expert Explanatory Rationale
Correct Answer: Take the medication with sips of water.
Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the neck. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?
Expert Explanatory Rationale
Correct Answer: Withhold the dose and notify the physician
Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.
When a client of Mexican American descent tells the nurse that she treated her infection by drinking milk, the nurse interprets the client's remark as:
Expert Explanatory Rationale
Correct Answer: Use of the first disease concept
In Mexican American culture, milk may be used as a traditional remedy for certain conditions, reflecting the ‘hot-cold' disease concept. It's not necessarily confusion, a laxative, or a dietary issue.
A client with a history of tuberculosis is prescribed isoniazid. Which supplement should the nurse administer concurrently?
Expert Explanatory Rationale
Correct Answer: Vitamin B6
Isoniazid can cause peripheral neuropathy due to vitamin B6 deficiency, so pyridoxine (vitamin B6) is administered to prevent this side effect.
A client with a history of bipolar disorder is prescribed lithium. The nurse should instruct the client to:
Expert Explanatory Rationale
Correct Answer: Maintain a consistent sodium intake.
Consistent sodium intake prevents lithium toxicity, as sodium fluctuations affect lithium levels.
You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
Expert Explanatory Rationale
Correct Answer: A prolapsed stoma
A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.
A 16-year-old Hispanic client at 10 weeks' gestation has been diagnosed with mild iron deficiency anemia. The client tells the nurse that she doesn't like to eat much meat. Which of the following foods should the nurse suggest to provide the client with the greatest amount of iron in her diet?
Expert Explanatory Rationale
Correct Answer: 1 cup of lentils
Lentils are a rich plant-based source of iron, providing significantly more iron per serving than sunflower seeds, cheese, or eggs, making them ideal for a client avoiding meat.
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