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NCLEX RN Questions with Detailed Explanations Questions

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Question 1 of 5

An infusion of lidocaine hydrochloride (Xylocaine) is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute?

Correct Answer: 2 mg/minute.

Rationale: Calculate: 1,000 mg in 250 mL = 4 mg/mL. At 30 mL/hour, that's 30 mL × 4 mg/mL = 120 mg/hour. Per minute: 120 mg ÷ 60 min = 2 mg/minute.

Question 2 of 5

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?

Question Image

Correct Answer: C

Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.

Question 3 of 5

A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?

Correct Answer: B

Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.

Question 4 of 5

The nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and fever. The priority nursing diagnosis for the client is:

Correct Answer: D

Rationale: Risk for injury is the priority due to unsteady gait and pain, which increase the likelihood of falls in a client with osteomyelitis.

Question 5 of 5

The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?

Correct Answer: A

Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.

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