NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?
Correct Answer: B
Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.
Question 2 of 5
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
Question 3 of 5
A client with a history of rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring regular liver function tests.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions is most important?
Correct Answer: A
Rationale: Avoiding swimming alone is critical for safety in epilepsy to prevent drowning during a seizure.
Question 5 of 5
Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?
Correct Answer: B
Rationale: Risk for injury is a priority nursing diagnosis for a child with hemophilia due to the risk of bleeding from minor trauma. Other diagnoses may apply but are less critical long-term.