RN NCLEX Practice Test
Question 1 of 5.
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
A. Fresh fruit
B. A milkshake
C. Saltine crackers and peanut butter
D. A ham and cheese sandwich
Explanation: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C, D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
Question 2 of 5.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
A. Two finger widths are noted between the axilla and the top of the crutch.
B. The client bears weight on his hands when ambulating.
C. The crutches and the client's feet move alternately.
D. The client bears weight on his axilla when standing.
Explanation: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
Question 3 of 5.
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
A. Shave the area before applying the patch
B. Remove the old patch and clean the skin with alcohol
C. Cover the patch with plastic wrap and tape it in place
D. Avoid cutting the patch because it will alter the dose
Explanation: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.
Question 4 of 5.
A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of:
A. Malpractice
B. Assault
C. Negligence
D. Battery
Explanation: Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.
Question 5 of 5.
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
A. Inspiratory stridor and harsh cough
B. Strident cough and drooling
C. Wheezing and intercostal retractions
D. Expiratory wheezing and nonproductive cough
Explanation: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.
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