NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
The nurse assesses a 7-month-old infant's growth and development. Which behavior should the nurse consider unusual?
Correct Answer: A
Rationale: Drinking from a cup with minimal spilling is advanced for a 7-month-old, who typically lacks such fine motor control.
Question 2 of 5
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should:
Correct Answer: A
Rationale: Increasing oxygen flow within the ordered range addresses increasing dyspnea and maintains oxygenation, which is the priority in suspected pulmonary embolism.
Question 3 of 5
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
Question 4 of 5
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
Question 5 of 5
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should:
Correct Answer: C
Rationale: Monitoring serum albumin assesses nutritional status, which is critical for skin integrity and preventing pressure ulcers. Walking is contraindicated for bed rest, catheters increase infection risk, and white blood cell count is less relevant.