NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client is receiving a continuous I.V. infusion of heparin. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: B
Rationale: Heparin is an anticoagulant, and its primary adverse effect is bleeding, which the nurse should monitor closely.
Question 2 of 5
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
Question 3 of 5
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
Question 4 of 5
Place the following phases of crisis in the correct sequential order. Order each response with a number from first to last, with #1 as the first phase of crisis to #4 which is the fourth phase of crisis. 1. The signs and symptoms of the General Adaptation Syndrome 2. Detachment and disorientation 3. Trying alternative methods of coping 4. The use of psychological ego defense mechanisms
Correct Answer: B
Rationale: The correct sequence of crisis phases typically follows: 1) General Adaptation Syndrome (initial stress response), 2) Detachment and disorientation (emotional response), 3) Trying alternative coping methods (problem-solving attempts), and 4) Use of psychological ego defense mechanisms (if coping fails). This reflects the progression of a crisis response.
Question 5 of 5
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
Correct Answer: A, C
Rationale: Diabetic ketoacidosis can cause hypokalemia (insulin shifts potassium) and hypophosphatemia (osmotic diuresis).