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
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.
Question 3 of 5
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
Correct Answer: D
Rationale: The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.
Question 4 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which symptom is most characteristic?
Correct Answer: A
Rationale: Elevated hCG levels are the most characteristic symptom of gestational trophoblastic disease reflecting abnormal trophoblastic proliferation. Fetal heart tones are absent uterine size is larger and fever is not typical.
Question 5 of 5
What is the most effective method to identify early breast cancer lumps?
Correct Answer: D
Rationale: Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective for women older than 40. Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.