NCLEX-RN
NCLEX RN Practice Test Free Questions
Extract:
Question 1 of 5
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
Question 2 of 5
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
Correct Answer: A
Rationale: Footling breech presentation often requires a Caesarean section due to risks of cord prolapse and delivery complications.
Question 3 of 5
The nurse is administering an intermittent tube feeding to a client through a nasogastric tube. Which of the following positions is optimal for tube feedings?
Correct Answer: A
Rationale: Elevating the head of the bed to 45° (
A) during tube feedings reduces the risk of aspiration and promotes digestion. A 90° elevation (
B) is excessive, 30° (
C) is insufficient, and a flat position (
D) increases aspiration risk.
Question 4 of 5
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
Correct Answer: B
Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.
Question 5 of 5
A home health nurse finds the client lying unconscious in the doorway of her bathroom. The nurse checks for responsiveness by gently shaking the client and calling her name. When it is determined that the client is nonresponsive, the nurse should:
Correct Answer: C
Rationale: Opening the airway is the first step in managing an unresponsive client to ensure adequate ventilation.