NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
Question 2 of 5
Homocysteine may be cleared from the blood with the help of which of the following vitamins?
Correct Answer: D
Rationale: Vitamin B6 (pyridoxine) aids in homocysteine metabolism, reducing blood levels. Other vitamins listed do not have this effect.
Question 3 of 5
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.
Question 4 of 5
The administration of an intramuscular injection to a neonate should be given in the:
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
Question 5 of 5
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right.
Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.