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
The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
Correct Answer: C
Rationale: Sundowning is a common phenomenon in dementia where confusion worsens in the late afternoon and evening.
Question 3 of 5
If a client is to have a nasogastric (NG) tube inserted for intermittent feedings, which of the following is an appropriate task to delegate to unlicensed assistive personnel?
Correct Answer: C
Rationale: Administering tube feedings (
C) can be delegated to unlicensed assistive personnel if trained, per facility policy. Inserting (
A), verifying (
B), and repositioning (
D) require nursing judgment.
Question 4 of 5
The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using:
Correct Answer: B
Rationale: A soft gauze pad is gentle and effective for cleaning the mouth in oral candidiasis without causing trauma.
Question 5 of 5
The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about:
Correct Answer: A
Rationale: With a platelet count of 80,000, the client is at risk for bleeding, so teaching bleeding precautions is critical to prevent complications.