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Free NCLEX Practice Exam with Answers 94th Edition
1. A nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with complaints of chills and back pain. The nurse notes that there is dark-colored urine in the Foley catheter drainage bag. The nurse interprets that the client is most likely experiencing which of the following reactions?
A. Delayed hemolytic
B. Acute hemolytic
C. Hyperkalemic
D. Allergic
Answer: B. Acute hemolytic
Rationale: The client is experiencing an acute hemolytic reaction to the transfusion. The nurse in this instance would immediately stop the infusion and notify the registered nurse who will then notify the physician. A delayed hemolytic reaction typically occurs from 2 to 14 days after transfusion. A hyperkalemic reaction occurs when blood is transfused that has been stored for too long, resulting in red blood cell hemolysis. The client experiencing a hyperkalemic type of reaction would exhibit nausea, muscle weakness or paresthesias, apprehension, bradycardia, ECG changes, and possibly cardiac arrest. An allergic reaction is characterized by flushing, nausea and vomiting, respiratory stridor, hypotension, and other signs of anaphylaxis.
Test-Taking Strategy: Focus on the data in the question. Noting the phrase “within an hour after the initiation of a transfusion” will direct you to option B. Review these types of reactions if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Fundamental Skills
References: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 450.
deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 723.
Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 521.
2. A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse would initially obtain which of the following medications from the emergency cart to have ready for use as ordered?
A. Aminophylline (theophylline)
B. Lidocaine
C. Norepinephrine
D. Epinephrine (Adrenalin)
Answer: D. Epinephrine (Adrenalin)
Rationale: The symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness. The nurse prepares to administer epinephrine and corticosteroid medications as ordered. Norepinephrine is a sympathetic agonist used to treat hypotension, but is not indicated in an allergic reaction. Lidocaine is an antidysrhythmic medication. Aminophylline is a bronchodilator, which could possibly be prescribed if needed to treat bronchospasm.
Test-Taking Strategy: Note the key word initially. This tells you that more than one or all of the options may be partially or totally correct. However, only one of the options is the initial action of the nurse. In this case, you would eliminate options 2 and 3 first. Select option 4 over option 1 because it is the first-line agent used in management of severe allergic (anaphylactic) reactions. Review the emergency treatment for a blood transfusion reaction if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 521.
McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 462-463.
3. A nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). The nurse tells the client to return to the clinic for follow-up laboratory studies of which of the following tests?
A. Liver function studies
B. Renal function studies
C. Glucose tolerance test
D. Electrolyte studies
Answer: A. Liver function studies
Rationale: Divalproex sodium, an anticonvulsant, can cause hepatotoxicity, which is potentially fatal. The nurse instructs the client to return to the clinic for follow-up liver function studies, such as lactate dehydrogenase (LDH), serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and ammonia levels. This is especially indicated in the first 6 months of therapy. The laboratory studies identified in options 2, 3, and 4 are not specifically related to the administration of this medication.
Test-Taking Strategy: To answer this question accurately, recall that this medication can lead to hepatotoxicity. This will direct you to option A. Review this medication if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Neurological
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 1094.
4. A client is seen by the physician, and Bell’s palsy is suspected. Which of the following signs and symptoms would the nurse expect to note in the client if this disorder is present?
A. Tingling sensations of the eyelid
B. Burning pain in the nose with intermittent facial paralysis
C. Speech or chewing difficulties accompanied by facial droop
D. Stabbing facial pain with intermittent tingling sensations in the eyes
Answer: C. Speech or chewing difficulties accompanied by facial droop
Rationale: Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles, increased lacrimation, speech or chewing difficulties, and painful sensations in the eye, in the face, or behind the ear. Options 1, 2, and 4 are not characteristics of Bell’s palsy.
Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are similar. Remember that a palsy is a type of paralysis. Knowing that the symptoms do not “come and go” (are not intermittent) helps you eliminate option 2 next. Review the signs and symptoms of Bell’s palsy if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 643.
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