NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?
Correct Answer: C
Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.
Question 2 of 5
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
Question 3 of 5
An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
Question 4 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of type 1 diabetes about sick day management. Which of the following instructions should be included? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Continuing insulin, frequent glucose monitoring, fluid intake, and contacting the provider prevent complications during illness.