NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the vital signs of a client with pancreatic cancer. In addition to routine vital signs, the nurse assesses the fifth vital sign of:
Correct Answer: B
Rationale: Pain is considered the fifth vital sign, alongside temperature, pulse, respiration, and blood pressure. It is routinely assessed, especially in conditions like pancreatic cancer, which often causes significant pain due to tumor invasion or obstruction.
Question 2 of 5
The nurse is caring for a client with a history of Rh sensitization. The physician orders a Kleihauer-Betke test. The purpose of this test is to:
Correct Answer: A
Rationale: The Kleihauer-Betke test quantifies fetal blood in maternal circulation critical in Rh sensitization to determine the dose of RhoGAM needed to prevent maternal antibody formation. It does not assess lung maturity antibodies or amniotic fluid volume.
Question 3 of 5
The client is receiving a continuous infusion of insulin for diabetic ketoacidosis. Which laboratory value should the nurse monitor most closely?
Correct Answer: A
Rationale: Insulin therapy in diabetic ketoacidosis shifts potassium into cells, risking hypokalemia, which can cause arrhythmias. Sodium, BUN, and A1C are monitored but are less critical during acute treatment.
Question 4 of 5
A client with type 2 diabetes is prescribed metformin (Glucophage). Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Stopping metformin abruptly (
C) can worsen glycemic control, indicating a need for further teaching. Taking with meals (
A), monitoring sugar (
B), and reporting muscle pain (
D) are correct.
Question 5 of 5
A 2-month-old infant is receiving IV fluids with a volume control set. The nurse uses this type of tubing because it:
Correct Answer: C
Rationale: A volume control set allows the nurse to control the amount of fluid administered over a set period.