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
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.
Question 3 of 5
A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:
Correct Answer: C
Rationale: Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.
Question 4 of 5
The physician has ordered an amniocentesis to determine the L/S ratio. The L/S ratio is a reliable indicator of:
Correct Answer: C
Rationale: The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity by measuring surfactant levels in amniotic fluid. A ratio of 2:1 or higher indicates mature lungs reducing the risk of respiratory distress syndrome. It does not assess renal function Rh isoimmunization or anatomical abnormalities.
Question 5 of 5
The charge nurse witnesses the nursing assistant hitting an elderly client in the long-term care facility. The nursing assistant can be charged with:
Correct Answer: C
Rationale: Hitting a client constitutes assault, a deliberate act causing harm or fear of harm. Negligence involves failure to act, tort is a broader legal term, and malpractice applies to professional errors, not intentional harm.