NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm.The white blood cell count is 16,000/mm³. Which of the following should the nurse identify as the immediate priority nursing diagnosis?
Correct Answer: B
Rationale: The symptoms indicate epiglottitis, with a high risk of airway obstruction due to epiglottal edema, making this the priority diagnosis.
Question 2 of 5
A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
Question 3 of 5
A client with a history of cirrhosis is prescribed propranolol (Inderal). The nurse should monitor the client for which of the following therapeutic effects?
Correct Answer: A
Rationale: Propranolol reduces portal hypertension by decreasing portal vein pressure in cirrhosis.
Question 4 of 5
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.
Question 5 of 5
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.