NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?
Correct Answer: A
Rationale: Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. Urine specific gravity does not necessarily indicate fluid volume excess. Edema may not be apparent, yet the client may have fluid volume excess.
Question 2 of 5
A client is admitted with symptoms of vertigo and syncope.
Correct Answer: C
Rationale: Left subclavian artery obstruction can cause subclavian steal syndrome, leading to vertigo, syncope, and radial pulse differences (>10 bpm) due to blood flow reversal. Memory loss (
A), numbness (
B), and headache (
D) are unrelated.
Question 3 of 5
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.
Question 4 of 5
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.
Question 5 of 5
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
Correct Answer: A
Rationale: Inotropic therapy will increase contractility, which will increase myocardial O2 demand. Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.