NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
Question 2 of 5
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
Question 3 of 5
The A, B, C, and Ds of a complete and comprehensive nutritional assessment includes:
Correct Answer: D
Rationale: A comprehensive nutritional assessment includes Anthropometric data (e.g., height, weight), Biochemical data (e.g., lab values), Clinical data (e.g., physical signs), and Dietary data (e.g., intake history).
Question 4 of 5
Which intervention would you expect to render to the client in a sickle cell anemia crisis?
Correct Answer: B
Rationale: Hydroxyurea is used in sickle cell anemia to reduce the frequency of crises by increasing fetal hemoglobin, which helps prevent sickling of red blood cells.
Question 5 of 5
A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Which of the following should the nurse determine? Select all that apply.
Correct Answer: C,D,E
Rationale: The nurse should assess for postpartum depression, pregnancy status, and breast-feeding, as these affect Depo-Provera's safety and efficacy. STDs and husband's willingness are not primary concerns.