NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
Correct Answer: A
Rationale: Chest drainage of 150 mL/hour post-CABG suggests significant bleeding, requiring immediate reporting to prevent hypovolemia. Confusion, pallor, and low urine output are less urgent.
Question 2 of 5
A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
Correct Answer: B
Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
Question 3 of 5
A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?
Correct Answer: B
Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (
A) is incorrect, pain-based use (
C) is wrong, and refrigeration (
D) is unnecessary.
Question 4 of 5
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.
Question 5 of 5
The nurse is caring for a client with a history of a tracheoesophageal fistula. The nurse should:
Correct Answer: D
Rationale: A tracheoesophageal fistula risks aspiration, requiring restricted oral intake until surgically repaired. Positioning, suctioning, and feedings are secondary or contraindicated.