NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
Correct Answer: B
Rationale: The IV line should not be discontinued because other IV medications will be needed. Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.
Question 2 of 5
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
Correct Answer: D
Rationale: Radiation site markings must be preserved for accurate treatment. Soap, lotion, or other substances can remove markings, so they should be avoided. Covering or powdering is unnecessary.
Question 3 of 5
A client with a history of heart failure is admitted with shortness of breath and leg edema. Which medication would the nurse expect to administer?
Correct Answer: B
Rationale: Furosemide, a diuretic, reduces fluid overload in heart failure, relieving shortness of breath and edema. Metoprolol (
A) manages heart rate, Warfarin (
C) prevents clots, and Atorvastatin (
D) lowers cholesterol, but none address fluid directly.
Question 4 of 5
The well child assessment of a one-year-old reveals orange discoloration of the nasolabial folds. Based on this finding the nurse should:
Correct Answer: A
Rationale: Orange discoloration of the nasolabial folds may result from excessive dietary beta-carotene (e.g. from carrots or sweet potatoes). Obtaining a diet history is the most appropriate action to identify the cause. The other options are more relevant for jaundice or liver issues.
Question 5 of 5
The nurse is caring for a client with a diagnosis of preeclampsia. Which laboratory finding is most concerning?
Correct Answer: A
Rationale: A platelet count of 80 000 indicates thrombocytopenia a serious complication in preeclampsia that increases bleeding risk and may signal HELLP syndrome. The other findings while concerning are less immediately alarming.