NCLEX-RN
NCLEX RN Practice Tests Questions
Extract:
Question 1 of 5
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.
Question 2 of 5
A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?
Correct Answer: A
Rationale: High Fowler's position with the head tilted forward (
A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B,
D) or using a neutral position in semi-Fowler's (
C) is less effective for this procedure.
Question 3 of 5
The nurse is caring for a client with a long history of taking magnesium hydroxide for managing symptoms of peptic ulcer disease. Which finding in the client's medical history would be of concern to the nurse?
Correct Answer: C
Rationale: Magnesium hydroxide can cause fluid retention, worsening heart failure. Other conditions are not directly affected.
Question 4 of 5
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
Correct Answer: C
Rationale: the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status
Question 5 of 5
The client using a diaphragm should be instructed to:
Correct Answer: D
Rationale: Surgery, especially pelvic or abdominal, can alter pelvic anatomy, requiring the diaphragm to be resized for effective contraception.