NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24 hour period?
Correct Answer: 720
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units/dose. Frequency: every 4 hours = 6 doses/day.
Total: 120 × 6 = 720 units.
Question 2 of 5
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
Correct Answer: D
Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.
Question 3 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
Question 4 of 5
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of 'bloody show.' The most appropriate nursing goal for this client would be:
Correct Answer: C
Rationale: In transition (9 cm dilation, frequent contractions), helping the client maintain control is critical due to intense contractions and emotional challenges.
Question 5 of 5
A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?
Correct Answer: C
Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.