NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (
A), administering naloxone (
C) to reverse effects, providing oxygen (
D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (
B) is not immediate.
Question 2 of 5
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
Question 3 of 5
The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
Question 4 of 5
An 82-year-old female complains of generalized fatigue and has new onset of urinary incontinence as well as anorexia, hyperventilation, and low-grade fever. The nurse anticipates that the client will be evaluated for which of the following?
Correct Answer: C
Rationale: Symptoms of fatigue, urinary incontinence, anorexia, and low-grade fever in an elderly female are classic for a urinary tract infection (
C). Diabetes (
A), bladder cancer (
B), and influenza (
D) are less likely to present with this combination of symptoms.
Question 5 of 5
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.