NCLEX-RN Practice Questions (Part 4)

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nclex practice questions

101. A clinical situation in which the increased release of erythropoietin would be expected is:

a. Hypoxemia
b. Hypotension
c. Hyperkalemia
d. Fluid overload

>>See answer and rationale<<

 

102. An age-related change in the kidney that leads to nocturia in an older adult is:

a. Decreased renal mass
b. Decreased detrusor muscle tone
c. Decreased ability to conserve sodium
d. Decreased ability to concentrate urine

>>See answer and rationale<<

 

103. During physical assessment of the urinary system, the nurse:

a. Auscultates the lower abdominal quadrants for fluid sounds
b. Palpates an empty bladder at the level of the symphysis pubis
c. Percusses the kidney with a firm blow at the posterior costovertebral angle
d. Positions the patient prone to palpate the kidneys with a posterior approach

>>See answer and rationale<<

 

104. A urinalysis of a urine specimen that is not processed within 1 hour may result in an erroneous measurement of:

a. Glucose
b. Bacteria
c. Specific gravity
d. White blood cells

>>See answer and rationale<<

 

105. Which of the following urine specific gravity values would indicate to the nurse that the patient is receiving excessive IV fluid therapy?

a. 1.002
b. 1.010
c. 1.025
d. 1.030

>>See answer and rationale<<

 

Neurologic System

 

106. A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

a. Caucasian race
b. Female sex
c. Obesity
d. Bronchial asthma

>>See answer and rationale<<

 

107. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

a. Take a hot bath.
b. Rest in an air-conditioned room
c. Increase the dose of muscle relaxants.
d. Avoid naps during the day

>>See answer and rationale<<

 

108. A male client is having tonic-clonic seizures. What should the nurse do first?

a. Elevate the head of the bed.
b. Restrain the client’s arms and legs.
c. Place a tongue blade in the client’s mouth.
d. Take measures to prevent injury.

>>See answer and rationale<<

 

109. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

a. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
b. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”
c. “It must be hard to accept the permanency of your paralysis.”
d. “You’ll first regain use of your legs and then your arms.”

>>See answer and rationale<<

 

110. The nurse is working on a surgical floor. The nurse must logroll a male client following a:

a. Laminectomy.
b. Thoracotomy.
c. Hemorrhoidectomy.
d. Cystectomy.

>>See answer and rationale<<

 

111. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

a. Immobilize the neck before the client is moved onto a stretcher.
b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
c. Place a cap over the client’s head.
d. Administer a sedative as ordered.

>>See answer and rationale<<

 

112. During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:

a. Use the pointed end of the reflex hammer when striking the Achilles tendon.
b. Support the joint where the tendon is being tested.
c. Tap the tendon slowly and softly
d. Hold the reflex hammer tightly.

>>See answer and rationale<<

 

113. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of care?

a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury

>>See answer and rationale<<

 

114. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?

a. Anxiety
b. Powerlessness
c. Ineffective denial
d. Risk for disuse syndrome

>>See answer and rationale<<

 

115. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

a. Prevent respiratory alkalosis.
b. Lower arterial pH.
c. Promote carbon dioxide elimination.
d. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

>>See answer and rationale<<

 

116. Nurse Maureen witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway in this victim by using which method?

a. Flexed position
b. Head tilt-chin lift
c. Jaw thrust maneuver
d. Modified head tilt-chin lift

>>See answer and rationale<<

 

117. The nurse is assessing the motor function of an unconscious male client. The nurse would use which of the following to test the client’s peripheral response to pain?

a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle

>>See answer and rationale<<

 

118. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of:

a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder

>>See answer and rationale<<

 

119. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg’s position
d. Side-lying, with the legs pulled up and head bent down onto the chest

>>See answer and rationale<<

 

120. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

a. Head mildline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees

>>See answer and rationale<<

 

121. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose

>>See answer and rationale<<

 

122. A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours

>>See answer and rationale<<

 

123. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

a. Loosening restrictive clothing
b. Restraining the client’s limbs
c. Removing the pillow and raising padded side rails
d. Positioning the client to side, if possible, with the head flexed forward

>>See answer and rationale<<

 

124. The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

a. The client has complete bilateral paralysis of the arms and legs.
b. The client has weakness on the right side of the body, including the face and tongue.
c. The client has lost the ability to move the right arm but is able to walk independently.
d. The client has lost the ability to move the right arm but is able to walk independently.

>>See answer and rationale<<

 

125. The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?

a. Giving the client thin liquids
b. Thickening liquids to the consistency of oatmeal
c. Placing food on the unaffected side of the mouth
d. Allowing plenty of time for chewing and swallowing

>>See answer and rationale<<

 

126. The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

a. Gets angry with family if they interrupt a task
b. Experiences bouts of depression and irritability
c. Has difficulty with using modified feeding utensils
d. Consistently uses adaptive equipment in dressing self

>>See answer and rationale<<

 

127. Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?

a. Speaking to the client at a slower rate
b. Allowing plenty of time for the client to respond
c. Completing the sentences that the client cannot finish
d. Looking directly at the client during attempts at speech

>>See answer and rationale<<

 

128. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

a. Getting too little exercise
b. Taking excess medication
c. Omitting doses of medication
d. Increasing intake of fatty foods

>>See answer and rationale<<

 

129. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

a. Eating large, well-balanced meals
b. Doing muscle-strengthening exercises
c. Doing all chores early in the day while less fatigued
d. Taking medications on time to maintain therapeutic blood levels

>>See answer and rationale<<

 

130. A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:

a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
c. Primary genetic in origin, triggered by exposure to meningitis
d. Primarily genetic in origin, triggered by exposure to neurotoxins

>>See answer and rationale<<

 

131. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:

a. Exposure to cold and drafts
b. Massage the face with a gentle upward motion
c. Perform facial exercises
d. Wrinkle the forehead, blow out the cheeks, and whistle

>>See answer and rationale<<

 

132. A female client is admitted to the hospital with a diagnosis of Guillain Barré syndrome. The nurse inquires during the nursing admission interview if the client has a history of:

a. Seizures or trauma to the brain
b. Meningitis during the last 5 years
c. Back injury or trauma to the spinal cord
d. Respiratory or gastrointestinal infection during the previous month.

>>See answer and rationale<<

 

133. A female client with GuillainBarré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?

a. Giving client full control over care decisions and restricting visitors
b. Providing positive feedback and encouraging active range of motion
c. Providing information, giving positive feedback, and encouraging relaxation
d. Providing intravenously administered sedatives, reducing distractions and limiting visitors

>>See answer and rationale<<

 

134. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety?

a. Speak loudly to the client
b. Test the temperature of the shower water
c. Check the temperature of the food on the delivery tray
d. Provide a clear path for ambulation without obstacles

>>See answer and rationale<<

 

135. A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior.

a. Is disoriented to person, place, and time
b. Affect is flat, with periods of emotional lability
c. Cannot recall what was eaten for breakfast today
d. Demonstrate inability to add and subtract; does not know who is president

>>See answer and rationale<<

 

136. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

a. Body temperature control
b. Balance and equilibrium
c. Visual acuity
d. Thinking and reasoning

>>See answer and rationale<<

 

137. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

a. Phenytoin (Dilantin)
b. Mannitol (Osmitrol)
c. Lidocaine (Xylocaine)
d. Furosemide (Lasix)

>>See answer and rationale<<

 

138. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

a. Give him a barbiturate.
b. Place him on mechanical ventilation.
c. Perform a lumbar puncture.
d. Elevate the head of his bed.

>>See answer and rationale<<

 

139. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:

a. Light flashes and floaters in front of the eye.
b. A recent driving accident while changing lanes.
c. Headaches, nausea, and redness of the eyes.
d. Frequent episodes of double vision.

>>See answer and rationale<<

 

140. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury

>>See answer and rationale<<

 

141. To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:

a. Stay with the client and encourage him to eat.
b. Help the client fill out his menu.
c. Give the client privacy during meals.
d. Fill out the menu for the client.

>>See answer and rationale<<

 

142. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following?

a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function

>>See answer and rationale<<

 

143. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

a. In 30 to 45 seconds
b. In 10 to 15 minutes
c. In 30 to 45 minutes
d. In 1 to 2 hours

>>See answer and rationale<<

 

144. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?

a. Parasympathomimetic agent
b. Sympatholytic agent
c. Adrenergic blocker
d. Cholinergic blocker

>>See answer and rationale<<

 

145. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?

a. Assessing the left leg
b. Assessing the pupils
c. Placing the client in Trendelenburg’s position
d. Assessing level of consciousness

>>See answer and rationale<<

 

146. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:

a. Increasing the exudative reaction of ocular tissue.
b. Decreasing leukocyte infiltration at the site of ocular inflammation.
c. Inhibiting the action of carbonic anhydrase.
d. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

>>See answer and rationale<<

 

147. Nurse April is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal?

a. More back pain than the first postoperative day
b. Paresthesia in the dermatomes near the wounds
c. Urine retention or incontinence
d. Temperature of 99.2° F (37.3° C)

>>See answer and rationale<<

 

148. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

a. Instilling one drop of pilocarpine 0.25% into both eyes daily.
b. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
c. Instilling one drop of pilocarpine 0.25% into the right eye daily.
d. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

>>See answer and rationale<<

 

149. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

a. The client leaves the side rails down.
b. The client uses a mirror to inspect the skin.
c. The client repositions only after being reminded to do so.
d. The client hangs the left arm over the side of the wheelchair.

>>See answer and rationale<<

 

150. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term?

a. Ataxic
b. Dystrophic
c. Helicopod
d. Steppage

>>See answer and rationale<<

 

151. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

a. A private room down the hall from the nurses’ station
b. An isolation room three doors from the nurses’ station
c. A semiprivate room with a 32-year-old client who has viral meningitis
d. A two-bed room with a client who previously had bacterial meningitis

>>See answer and rationale<<

 

152. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine?

a. Ulcerative colitis
b. Blood dyscrasia
c. Intestinal obstruction
d. Spinal cord injury

>>See answer and rationale<<

 

153. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note:

a. Vertigo, tinnitus, and hearing loss.
b. Vertigo, vomiting, and nystagmus
c. Vertigo, pain, and hearing impairment.
d. Vertigo, blurred vision, and fever.

>>See answer and rationale<<

 

154. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

a. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.”
b. “Try to ambulate independently after about 24 hours.”
c. “Shampoo your hair every day for 10 days to help prevent ear infection.”
d. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.”

>>See answer and rationale<<

 

155. Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?

a. Excessive tearing
b. Urine retention
c. Muscle weakness
d. Slurred speech

>>See answer and rationale<<

 

156. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

a. Tachycardia
b. Increased salivation
c. Hypotension
d. Apnea

>>See answer and rationale<<

 

157. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign highest priority to which nursing diagnosis?

a. Impaired physical mobility
b. Ineffective breathing pattern
c. Disturbed sensory perception (tactile)
d. Self-care deficient: Dressing/grooming

>>See answer and rationale<<

 

158. A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:

a. Long-term treatment of epilepsy.
b. Postoperative pain management of laminectomy clients.
c. Postoperative pain management of diskectomy clients
d. Treatment of spasticity associated with spinal cord lesions.

>>See answer and rationale<<

 

159. A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:

a. Introducing ice water into the external auditory canal.
b. Touching the cornea with a wisp of cotton.
c. Turning the client’s head suddenly while holding the eyelids open.
d. Shining a bright light into the pupil.

>>See answer and rationale<<

 

160. While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

a. The client may be less sensitive to the effects of a neuromuscular blocking agent.
b. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.
c. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.
d. Pancuronium and succinylcholine both require cautious administration.

>>See answer and rationale<<

 

161. A male client is color blind. The nurse understands that this client has a problem with:

a. Rods.
b. Cones.
c. Lens.
d. Aqueous humor.

>>See answer and rationale<<

 

162. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

a. Diencephalon
b. Medulla
c. Midbrain
d. Cortex

>>See answer and rationale<<

 

163. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

a. Vision changes
b. Absent deep tendon reflexes
c. Tremors at rest
d. Flaccid muscles

>>See answer and rationale<<

 

164. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

a. Sit with the client for a few minutes.
b. Administer an analgesic.
c. Inform the nurse manager.
d. Call the physician immediately.

>>See answer and rationale<<

 

165. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:

a. Cranial nerves I and II.
b. Cranial nerves III and V.
c. Cranial nerves VI and VIII.
d. Cranial nerves IX and X.

>>See answer and rationale<<

 

Pharmacology

 

166.  Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. A nurse reviews the client’s medical record and would question the prescription if which of the following is noted in the client’s history?

a. Neuralgia
b. Insomnia
c. Use of nitroglycerin
d. Use of multivitamins

>>See answer and rationale<<

 

167.  A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?

a. “I will take my pills every day at the same time.”
b. “I will be certain to avoid alcohol consumption.”
c. “I have already called my family to pick up a Medic-Alert bracelet.”
d. “I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated.”

>>See answer and rationale<<

 

168.  Heparin sodium is prescribed for the client. The nurse expects that the health care provider will prescribe which of the following to monitor for a therapeutic effect of the medication?

a. Hematocrit level
b. Hemoglobin level
c. Prothrombin time (PT)
d. Activated partial thromboplastin time (aPTT)

>>See answer and rationale<<

 

169.  A nurse is monitoring a client who is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol?

a. The development of complaints of insomnia
b. The development of audible expiratory wheezes
c. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
d. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication

>>See answer and rationale<<

 

170.) Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

a. Pallor
b. Drowsiness
c. Bradycardia
d. Restlessness

>>See answer and rationale<<

 

171. A client with myasthenia gravis is suspected of having cholinergic crisis. Which of the following indicate that this crisis exists?

a. Ataxia
b. Mouth sores
c. Hypotension
d. Hypertension

>>See answer and rationale<<

 

172.  A client with myasthenia gravis is receiving pyridostigmine (Mestinon). The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?

a. Vitamin K
b. Atropine sulfate
c. Protamine sulfate
d. Acetylcysteine (Mucomyst)

>>See answer and rationale<<

 

173. Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson’s disease, and the nurse monitors the client for adverse reactions to the medication. Which of the following indicates that the client is experiencing an adverse reaction?

a. Pruritus
b. Tachycardia
c. Hypertension
d. Impaired voluntary movements

>>See answer and rationale<<

 

174. Phenytoin (Dilantin), 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?

a. “I will use a soft toothbrush to brush my teeth.”
b. “It’s all right to break the capsules to make it easier for me to swallow them.”
c. “If I forget to take my medication, I can wait until the next dose and eliminate that dose.”
d. “If my throat becomes sore, it’s a normal effect of the medication and it’s nothing to be concerned about.”

>>See answer and rationale<<

 

175. A client is taking phenytoin (Dilantin) for seizure control and a sample for a serum drug level is drawn. Which of the following indicates a therapeutic serum drug range?

a. 5 to 10 mcg/mL
b. 10 to 20 mcg/mL
c. 20 to 30 mcg/mL
d. 30 to 40 mcg/mL

>>See answer and rationale<<

 

176. Ibuprofen (Advil) is prescribed for a client. The nurse tells the client to take the medication:

a. With 8 oz of milk
b. In the morning after arising
c. 60 minutes before breakfast
d. At bedtime on an empty stomach

>>See answer and rationale<<

 

177. A nurse is caring for a client who is taking phenytoin (Dilantin) for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which of the following information should the nurse provide to the client?

a. Pregnancy should be avoided while taking phenytoin (Dilantin).
b. The client may stop taking the phenytoin (Dilantin) if it is causing severe gastrointestinal effects.
c. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin (Dilantin).
d. The increased risk of thrombophlebitis exists while taking phenytoin (Dilantin) and birth control pills together.

>>See answer and rationale<<

 

178. A client with trigeminal neuralgia is being treated with carbamazepine (Tegretol). Which laboratory result would indicate that the client is experiencing an adverse reaction to the medication?

a. Sodium level, 140 mEq/L
b. Uric acid level, 5.0 mg/dL
c. White blood cell count, 3000 cells/mm3
d. Blood urea nitrogen (BUN) level, 15 mg/dL

>>See answer and rationale<<

 

179. Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds, knowing that the therapeutic action of this medication is which of the following?

a. Depresses spinal reflexes
b. Acts directly on the skeletal muscle to relieve spasticity
c. Acts within the spinal cord to suppress hyperactive reflexes
d. Acts on the central nervous system (CNS) to suppress spasms

>>See answer and rationale<<

 

180. A nurse is reviewing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which laboratory test would identify an adverse effect associated with the administration of this medication?

a. Creatinine
b. Liver function tests
c. Blood urea nitrogen
d. Hematological function tests

>>See answer and rationale<<

 

181. Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client’s record. Which of the following disorders, if noted in the client’s record, would indicate a need to contact the health care provider regarding the administration of this medication?

a. Glaucoma
b. Emphysema
c. Hyperthyroidism
d. Diabetes mellitus

>>See answer and rationale<<

 

182. Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. The nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?

a. A history of hyperthyroidism
b. A history of diabetes insipidus
c. When the last full meal was consumed
d. When the last alcoholic drink was consumed

>>See answer and rationale<<

 

183. A nurse is collecting data from a client and the client’s spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder would the nurse suspect that this client may have based on the use of this medication?

a. Dementia
b. Schizophrenia
c. Seizure disorder
d. Obsessive-compulsive disorder

>>See answer and rationale<<

 

184.  Fluoxetine (Prozac) is prescribed for the client. The nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?

a. “I should take the medication with my evening meal.”
b. “I should take the medication at noon with an antacid.”
c. “I should take the medication in the morning when I first arise.”
d. “I should take the medication right before bedtime with a snack.”

>>See answer and rationale<<

 

185.  A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan?

a. Reports not going to work for this past week
b. Complains of not being able to “do anything” anymore
c. Arrives at the clinic neat and appropriate in appearance
d. Reports sleeping 12 hours per night and 3 to 4 hours during the day

>>See answer and rationale<<

 

186.  A nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). What information would be important for the nurse to gather regarding the adverse effects related to the medication?

a. Cardiovascular symptoms
b. Gastrointestinal dysfunctions
c. Problems with mouth dryness
d. Problems with excessive sweating

>>See answer and rationale<<

 

187.  A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which of the following would indicate medication effectiveness?

a. No rapid heartbeats or anxiety
b. No paranoid thought processes
c. No thought broadcasting or delusions
d. No reports of alcohol withdrawal symptoms

>>See answer and rationale<<

 

188.  A client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of bupropion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which of the following?

a. Insomnia
b. Weight gain
c. Seizure activity
d. Orthostatic hypotension

>>See answer and rationale<<

 

189.  A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply.

a. Figs
b. Yogurt
c. Crackers
d. Aged cheese
e Tossed salad
f. Oatmeal cookies

>>See answer and rationale<<

 

190.  A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which of the following is the most reliable indicator of hypoglycemia?

a. Sweating
b. Tachycardia
c. Nervousness
d. Low blood glucose level

>>See answer and rationale<<

 

191.  A nurse is preparing to administer digoxin (Lanoxin), 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication?

a. Heart rate
b. Temperature
c. Respirations
d. Blood pressure

>>See answer and rationale<<

 

192. A nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which of the following should the nurse recognize as a potential adverse effect Select all that apply.

a. Nausea
b. Tinnitus
c. Hypotension
d. Hypokalemia
e. Photosensitivity
f. Increased urinary frequency

>>See answer and rationale<<

 

193.  A nurse is providing instructions to an adolescent who has a history of seizures and is taking an anticonvulsant medication. Which of the following statements indicates that the client understands the instructions?

a. “I will never be able to drive a car.”
b. “My anticonvulsant medication will clear up my skin.”
c. “I can’t drink alcohol while I am taking my medication.”
d. “If I forget my morning medication, I can take two pills at bedtime.”

>>See answer and rationale<<

 

194. A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a β-blocker, digoxin (Lanoxin), and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis?

a. Dyspnea, edema, and palpitations
b. Chest pain, hypotension, and paresthesia
c. Double vision, loss of appetite, and nausea
d. Constipation, dry mouth, and sleep disorder

>>See answer and rationale<<

 

195.  A client is being treated for acute congestive heart failure with intravenously administered bumetanide. The vital signs are as follows: blood pressure, 100/60 mm Hg; pulse, 96 beats/min; and respirations, 24 breaths/min. After the initial dose, which of the following is the priority assessment?

a. Monitoring weight loss
b. Monitoring temperature
c. Monitoring blood pressure
d. Monitoring potassium level

>>See answer and rationale<<

 

196. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, a nurse ensures that which of the following medications is available on the nursing unit?

a. Protamine sulfate
b. Potassium chloride
c. Phytonadione (vitamin K )
d. Aminocaproic acid (Amicar)

>>See answer and rationale<<

 

197.  Meperidine hydrochloride (Demerol) is prescribed for the client with pain. Which of the following would the nurse monitor for as a side effect of this medication?

a. Diarrhea
b. Bradycardia
c. Hypertension
d. Urinary retention

>>See answer and rationale<<

 

198. Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client’s health history, knowing that this medication is contraindicated if which of the following disorders is present?

a. Headaches
b. Liver disease
c. Hypothyroidism
d. Diabetes mellitus

>>See answer and rationale<<

 

199.  A client receives a prescription for methocarbamol (Robaxin), and the nurse reinforces instructions to the client regarding the medication. Which client statement would indicate a need for further instructions?

a. “My urine may turn brown or green.”
b. “This medication is prescribed to help relieve my muscle spasms.”
c. “If my vision becomes blurred, I don’t need to be concerned about it.”
d. “I need to call my doctor if I experience nasal congestion from this medication.

>>See answer and rationale<<

 

200. Atenolol hydrochloride (Tenormin) is prescribed for a hospitalized client. The nurse should perform which of the following as a priority action before administering the medication?

a. Listen to the client’s lung sounds.
b. Check the client’s blood pressure.
c. Check the recent electrolyte levels.
d. Assess the client for muscle weakness.

>>See answer and rationale<<

 

More NCLEX Questions:

NCLEX-RN Practice Questions (Part 1)

NCLEX-RN Practice Questions (Part 2)

NCLEX-RN Practice Questions (Part 3)