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NCLEX NCLEX-RN Exam Questions
National Council Licensure Examination - NCLEX-RN (Page 33 )

Updated On: 10-Mar-2026
Page 33 of 345
PDF with 862 Questions

When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

  1. Stephens-Johnson syndrome
  2. Folate deficiency
  3. Leukopenic aplastic anemia
  4. Granulocytosis and nephrosis

Answer(s): A

Explanation:

(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).



A client with a C-3­4 fracture has just arrived in the emergency room. The primary nursing intervention is:

  1. Stabilization of the cervical spine
  2. Airway assessment and stabilization
  3. Confirmation of spinal cord injury
  4. Normalization of intravascular volume

Answer(s): B

Explanation:

(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.



A client with a C-3­4 fracture has just arrived in the emergency room. The primary nursing intervention is:

  1. Stabilization of the cervical spine
  2. Airway assessment and stabilization
  3. Confirmation of spinal cord injury
  4. Normalization of intravascular volume

Answer(s): B

Explanation:

(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.



Dietary planning is an essential part of the diabetic client's regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

  1. 50% complex carbohydrate, 20%­25% protein, 20%­25% fat
  2. 45% complex carbohydrate, 25%­30% protein, 30%­35% fat
  3. 70% complex carbohydrate, 20%­30% protein, 10%­20% fat
  4. 60% complex carbohydrate, 12%­15% protein, 20%­25% fat

Answer(s): D

Explanation:

(A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability.



Dietary planning is an essential part of the diabetic client's regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

  1. 50% complex carbohydrate, 20%­25% protein, 20%­25% fat
  2. 45% complex carbohydrate, 25%­30% protein, 30%­35% fat
  3. 70% complex carbohydrate, 20%­30% protein, 10%­20% fat
  4. 60% complex carbohydrate, 12%­15% protein, 20%­25% fat

Answer(s): D

Explanation:

(A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability.



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