NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing an adult female client for hypovolemia.
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (
B) and BUN (
D) are within normal ranges, and urine specific gravity (
C) is normal, not elevated as expected in hypovolemia.
Question 2 of 5
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
Question 3 of 5
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (
A) is unreliable, stridor (
B) suggests obstruction, and carbonaceous particles (
D) indicate smoke inhalation.
Question 4 of 5
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
Question 5 of 5
The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.