NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?
Correct Answer: C
Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.
Question 2 of 5
The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
Question 3 of 5
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
Question 4 of 5
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
Question 5 of 5
A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.