NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The client is receiving chemotherapy for breast cancer. Which instruction should the nurse include to prevent infection?
Correct Answer: A
Rationale: Chemotherapy causes immunosuppression, increasing infection risk. Avoiding crowds and sick individuals reduces exposure to pathogens. The other measures are helpful but less effective at preventing infection.
Question 2 of 5
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
Correct Answer: B
Rationale: Intravenous pyelogram uses iodine-based contrast, which can cause allergic reactions, especially in clients with shellfish/iodine allergies. Identifying allergies is the highest priority for safety.
Question 3 of 5
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
Correct Answer: D
Rationale: Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. (A, B,
C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
Question 4 of 5
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
Question 5 of 5
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
Correct Answer: D
Rationale: Metabolic acidosis is determined by low pH and HCO3.