NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
Correct Answer: C
Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.
Question 2 of 5
The nurse is caring for a client with a suspected urinary tract infection. Which symptom is most common?
Correct Answer: A
Rationale: Dysuria (painful urination) is the most common symptom of a urinary tract infection, reflecting bladder or urethral irritation.
Question 3 of 5
A 36-month-old child weighing 44 lb is to receive ceftriaxone (Rocephin) 2 g I.V. every 12 hours. The recommended dose of Rocephin is 50 to 75 mg/kg/day in divided doses. The nurse should:
Correct Answer: D
Rationale: 44 lb = 20 kg. Recommended dose: 50-75 mg/kg/day = 1000-1500 mg/day. 2 g (2000 mg) every 12 hours = 4000 mg/day, exceeding the safe dose, so the nurse should notify the physician.
Question 4 of 5
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
Question 5 of 5
Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?
Correct Answer: B
Rationale: Risk for injury is a priority nursing diagnosis for a child with hemophilia due to the risk of bleeding from minor trauma. Other diagnoses may apply but are less critical long-term.