NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and should tell the parent that the second vaccine is administered at which time periods?
Correct Answer: D
Rationale: The vaccination schedule for an infant whose mother tests negative for hepatitis B consists of a series of 3 immunizations given at 0 months (birth), 1 to 2 months of age, and then 6 months after the initial dose. An infant whose mother tests positive receives hepatitis B immune globulin along with the first dose of the hepatitis vaccine within 12 hours of birth.
Question 2 of 5
The nurse is caring for a client who has just undergone a lumbar puncture. Which of the following interventions is most appropriate in the immediate post-procedure period?
Correct Answer: B
Rationale: Keeping the client flat for 4-6 hours post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.
Question 3 of 5
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia due to potassium loss in urine. Monitoring serum potassium is critical to prevent arrhythmias or muscle weakness.
Question 4 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 5 of 5
You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients?
Correct Answer: A
Rationale: Accepting impending death is a common and appropriate goal for hospice clients, as it aligns with the focus of palliative care on achieving peace and closure at the end of life.