NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
Correct Answer: C
Rationale: Anterior wall myocardial infarction increases the risk of left ventricular failure, leading to pulmonary edema, characterized by weakness, shortness of breath, and crackles.
Question 2 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 3 of 5
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 50 gtt/min.
Question 4 of 5
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
Correct Answer: C
Rationale: A recheck after antibiotic therapy for otitis media confirms resolution of the infection, ensuring no persistent effusion or complications. Hearing tests or new prescriptions are not routinely needed.
Question 5 of 5
The nurse is caring for a client with a recent stroke. Which position is most appropriate for this client?
Correct Answer: C
Rationale: Side-lying with the head elevated 30 degrees reduces intracranial pressure and promotes venous drainage in stroke clients, minimizing complications like cerebral edema. Supine, prone, or sitting positions may increase pressure or risk aspiration.