NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
Question 2 of 5
Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client?
Correct Answer: D
Rationale:
Total bilirubin of 17 umol/L (1 mg/dL) is elevated (normal 0.1-1.0 mg/dL), indicating potential liver or biliary issues, requiring reporting.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of type 1 diabetes about sick day management. Which of the following instructions should be included? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Continuing insulin, frequent glucose monitoring, fluid intake, and contacting the provider prevent complications during illness.
Question 4 of 5
The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.
Question 5 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?
Correct Answer: B
Rationale: Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.