NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

The nurse begins administration of blood to a client on a medical unit. The nurse knows that which of the following activities is inappropriate to delegate to the unlicensed assistive personnel (UAP)?

Correct Answer: C

Rationale: Explaining the reason for a transfusion requires clinical knowledge and is outside the UAP’s scope. Other tasks are appropriate for delegation.

Question 2 of 5

A client has suffered a severe traumatic brain injury and is being treated in the ICU. Which of the following interventions does the nurse anticipate to control intracranial pressure? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: ICP control includes elevating head (
A), oxygenating (
B), neutral alignment (
C), sedation (
D), and hypothermia (E) to reduce swelling and metabolic demand.

Question 3 of 5

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

Correct Answer: D

Rationale: Checking the site for bleeding ensures early detection of hematoma or excessive bleeding post-heparin injection.

Question 4 of 5

A client with congestive heart failure has been receiving digoxia (Laxoxin). Which finding indicates that the medication is having a desired effect?

Correct Answer: A

Rationale: Digoxin improves cardiac output in congestive heart failure, leading to increased urinary output due to enhanced renal perfusion.

Question 5 of 5

A client with burns is admitted and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours; the client's CVP reading is 14 cm/Hâ‚‚O. Which evaluation by the nurse would be most accurate?

Correct Answer: D

Rationale: A CVP of 14 cm/Hâ‚‚O (normal: 3-8 cm/Hâ‚‚O) indicates fluid volume excess, likely from aggressive resuscitation, requiring careful monitoring to prevent complications.

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