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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 10 )

Updated On: 12-Jan-2026
Page 10 of 345
PDF with 862 Questions

A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

  1. Respiratory alkalosis
  2. Respiratory acidosis
  3. Metabolic alkalosis
  4. Metabolic acidosis

Answer(s): B

Explanation:

(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.



Primary nursing diagnoses for the antisocial client are:

  1. Alteration in perception and altered self-concept
  2. Impaired social interaction, ineffective individual coping, and altered self-concept
  3. Altered communication processes and altered recreational patterns
  4. Altered body image and altered thought processes

Answer(s): B

Explanation:

(A) This answer is incorrect. Perception is not altered because the client is not psychotic. (B) This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. (C) This answer is incorrect. Altered communication processes do not characterize this client.
The antisocial person communicates well and tends to have a charming personality. (D) This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.



A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

  1. 0.5 ng/mL
  2. 1.0 ng/mL
  3. 2.0 ng/mL
  4. 3.0 ng/mL

Answer(s): D

Explanation:

(A) 0.5 ng/mL of digoxin is a subtherapeutic level, not a toxic one. (B) 1.0 ng/mL is a therapeutic level. (C) 2.0 ng/mL is a therapeutic level. (D) Digoxin's therapeutic level is 0.8­2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.



A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:

  1. 10 days
  2. 2­4 weeks
  3. 2 months
  4. 3 months

Answer(s): B

Explanation:

(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2­4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy.



A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection?

  1. Acute
  2. Chronic
  3. Hyperacute
  4. Hyperchronic

Answer(s): A

Explanation:

(A) The sudden development of fever, graft tenderness, increased white blood count, and malaise are signs and symptoms of an acute rejection that commonly occurs at 3 months. (B) Chronic rejection occurs slowly over a period of months to years and mimics chronic renal failure. (C) Hyperacute rejection occurs immediately after surgery up to 48 hours postoperatively. (D) Hyperchronic rejection is not a type of rejection.



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