Free NCLEX RN Exam
Question 1 of 5.
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
A. Administer her next dosage of lithium, and then call the physician.
B. Withhold her lithium, and report her symptoms to the physician.
C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Explanation: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
Question 2 of 5.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
A. Sodium
B. Potassium
C. Protein
D. Fat
Explanation: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
Question 3 of 5.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
A. Ignore the client's behavior.
B. Exchange the cards for a checker board.
C. Send the other clients to their rooms.
D. Cover the client and walk her to her room.
Explanation: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 4 of 5.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
A. I can help control my weight by switching from sugar to Nutrasweet.
B. I need to resume my old diet before becoming pregnant.
C. I need to eliminate most sources of phenylalanine from my diet.
D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Explanation: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
Question 5 of 5.
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
A. Loss of the myelin sheath in portions of the brain and spinal cord
B. An interruption in the transmission of impulses from nerve endings to muscles
C. Progressive weakness and loss of sensation that begins in the lower extremities
D. Loss of coordination and stiff 'cogwheel' rigidity
Explanation: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.