NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's physician?
Correct Answer: B
Rationale: Difficulty recalling the day of the week suggests neurological impairment, which is critical to report in a child with a brain tumor, as it may indicate tumor progression or increased intracranial pressure.
Question 2 of 5
A client is admitted with a suspected myocardial infarction. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: Obtaining a 12-lead ECG is the priority to confirm myocardial infarction and guide treatment.
Question 3 of 5
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.
Question 4 of 5
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
Question 5 of 5
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.