NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
A client just been diagnosed with acute kidney injury has a serum potassium level of 6.1 mEq/L (6.1 mmol/L). Which action should the nurse take immediately?
Correct Answer: B
Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and resultant cardiac arrest. Because of this, the primary health care provider must be notified at once so that the client may receive definitive treatment. The nurse might also check the result of a serum sodium level, but this is not a priority action of the nurse. Fluid intake would not be increased because it would contribute to fluid overload and would not effectively lower the serum potassium level. Dietary teaching may be necessary at some point, but this action is not the priority.
Question 2 of 5
The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client?
Correct Answer: B
Rationale: The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
Question 3 of 5
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
Question 4 of 5
The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which of the following? Select all that apply.
Correct Answer: A,B,D
Rationale: Bacterial meningitis in infants commonly presents with fever, vomiting, and poor feeding. Diarrhea and abdominal pain are less typical symptoms in this age group.
Question 5 of 5
The nurse is assessing a client with suspected pulmonary edema. Which finding supports this diagnosis?
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in the alveoli, a key sign of pulmonary edema requiring urgent intervention.