NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
Question 2 of 5
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.
Question 3 of 5
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.
Question 4 of 5
A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, 'It's my fault. My Mom is going to kill me. I don't even have a way home.' Which of the following should be the nurse's initial intervention?
Correct Answer: A
Rationale: This intervention calms the client's hysteria using physical touch and breathing techniques, helping her regain composure before addressing other concerns.
Question 5 of 5
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.