NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
Before giving methergine postpartum, the nurse should assess the client for:
Correct Answer: B
Rationale: Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. Flushing is not a side effect of methergine. Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
Question 2 of 5
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
Question 3 of 5
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
Correct Answer: D
Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
Question 4 of 5
The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.
Question 5 of 5
A client is scheduled for a biologic heart valve replacement. The nurse is aware that the client will require:
Correct Answer: C
Rationale: Biologic (tissue) heart valves are prone to bacterial endocarditis. Strict dental hygiene prevents infections that could seed the valve. Lifelong anticoagulation is typically for mechanical valves and the other options are not specific to biologic valves.