NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of septic shock. Which intervention is the priority?
Correct Answer: A
Rationale: In septic shock, administering IV antibiotics within the first hour is the priority to target the infection causing shock. Vasopressors, catheterization, and cultures are secondary.
Question 2 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 3 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
Question 4 of 5
The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
Correct Answer: B
Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.
Question 5 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.