NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application?
Correct Answer: D
Rationale: Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application, especially with fractures near the elbow.
Question 2 of 5
A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24 hour period?
Correct Answer: 720
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units/dose. Frequency: every 4 hours = 6 doses/day.
Total: 120 × 6 = 720 units.
Question 3 of 5
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.
Question 4 of 5
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
Correct Answer: D
Rationale: Weighing a child with nephrosis is to assess for edema, not nutrition. (B,
C) This is not the purpose for weighing the child. Weight and measurement are the primary ways of evaluating edema and fluid shifts.
Question 5 of 5
The nurse is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.