NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.
Question 2 of 5
A client with a history of peptic ulcer disease is admitted with abdominal pain. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: Pantoprazole reduces acid production, promoting ulcer healing.
Question 3 of 5
The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?
Correct Answer: A
Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.
Question 4 of 5
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
Question 5 of 5
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.