NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 2 of 5
A client with a history of hepatitis C is admitted with complaints of fatigue. The nurse should expect the client to have:
Correct Answer: A
Rationale: Hepatitis C causes liver inflammation, leading to elevated liver enzymes (e.g., AST, ALT), a common finding reflecting hepatic damage.
Question 3 of 5
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
Correct Answer: A
Rationale: Pressure garments apply uniform pressure to prevent or reduce hypertrophic scarring, which is critical during the recovery phase of burn care.
Question 4 of 5
A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?
Correct Answer: B
Rationale: A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. Streptokinase activates plasminogen, dissolving fibrin deposits.
To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. The client is kept on bed rest for 8-12 hours following the procedure because of the potential for bleeding.
Question 5 of 5
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 50 gtt/min.