NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
Question 2 of 5
The client with a history of preterm labor is being monitored at 28 weeks gestation. The physician orders betamethasone (Celestone). The rationale for administering betamethasone is to:
Correct Answer: C
Rationale: Betamethasone a corticosteroid is given to women in preterm labor (24-34 weeks) to enhance fetal lung maturity by promoting surfactant production reducing the risk of respiratory distress syndrome. It does not prevent infection stimulate labor or prevent bleeding.
Question 3 of 5
A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?
Correct Answer: A
Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.
Question 4 of 5
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.
Question 5 of 5
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.