NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (
A) is unreliable, stridor (
B) suggests obstruction, and carbonaceous particles (
D) indicate smoke inhalation.
Question 2 of 5
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
Correct Answer: C
Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.
Question 3 of 5
The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.
Question 4 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client’s heart rate is 58 beats per minute. What is the nurse’s best action?
Correct Answer: B
Rationale: A heart rate of 58 bpm is below the threshold (60 bpm) for digoxin administration, as it may worsen bradycardia. Holding the dose and notifying the physician (
B) is safest. Administering (
A), reducing (
C), or delaying (
D) is inappropriate.
Question 5 of 5
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
Correct Answer: A
Rationale: Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in most individuals. Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. Occlusion of the circumflex artery does not cause bradycardia. Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.