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 pregnant woman has experienced repeated vaginal monilial infections. When educating the client about the infection, which information should the nurse include? Select all that apply.
Correct Answer: A,B,C
Rationale: Daily bathing (
A), understanding estrogen's role in yeast growth (
B), and wearing cotton panties (
C) help manage monilial infections. Panty liners (
D) may trap moisture, and avoiding panties (E) is impractical.
Question 3 of 5
The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:
Correct Answer: A
Rationale: Hanging the solution 2-3 feet above the abdomen ensures proper flow by gravity without excessive pressure, maintaining effective irrigation.
Question 4 of 5
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
Correct Answer: A
Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (
A). Cognitive impairment (
B), vision impairment (
C), and anxiety (
D) do not typically present with these specific behaviors.
Question 5 of 5
A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?
Correct Answer: B
Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.