NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
Question 2 of 5
The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
Question 3 of 5
The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client's symptoms, the nurse should suspect which complication of central line use?
Correct Answer: B
Rationale: Sudden dyspnea, chest pain, and confusion post-central line removal suggest an air embolus, a serious complication requiring immediate intervention.
Question 4 of 5
During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.
Correct Answer: B,C,E
Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).
Question 5 of 5
The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:
Correct Answer: A
Rationale: Hanging the solution 2-3 feet above the abdomen ensures proper flow by gravity without excessive pressure, maintaining effective irrigation.