NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level, drawn two hours ago, is 30 mcg/mL. What is the appropriate nursing action?
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is toxic (therapeutic range: 10–20 mcg/mL). Holding the dose and notifying the physician prevents toxicity. Administering (
A), decreasing (
C), or increasing (
D) the dose without physician input is unsafe.
Question 2 of 5
One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
Correct Answer: A
Rationale: Sock and mitten burns (circumferential burns on hands and feet) are suggestive of immersion in hot water, inconsistent with a simple fall, raising suspicion of abuse.
Question 3 of 5
The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which intervention is most appropriate?
Correct Answer: A
Rationale: Gestational trophoblastic disease requires monitoring hCG levels to assess for resolution or progression to malignancy (e.g. choriocarcinoma).
Tocolytics fetal monitoring and vaginal delivery are not indicated as there is no viable fetus.
Question 4 of 5
The initial treatment for a client with a liquid chemical burn injury is to:
Correct Answer: B
Rationale: The use of large amounts of water to flush the area is recommended for chemical burns to dilute and remove the chemical. Neutralizing solutions may extend the burn, calcium chloride is not indicated, and lanolin is not beneficial initially.
Question 5 of 5
The nurse is caring for a client with a diagnosis of hyperemesis gravidarum. Which intervention is most appropriate?
Correct Answer: D
Rationale: Hyperemesis gravidarum requires IV fluids for hydration small frequent meals to reduce nausea and antiemetics to control vomiting. All interventions are appropriate to manage symptoms and prevent complications.