NCLEX-RN
Free NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
Question 2 of 5
The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?
Correct Answer: B
Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.
Question 3 of 5
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.
Question 4 of 5
The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?
Correct Answer: C
Rationale: Cyanotic ear lobes indicate severe hypoxemia, a late sign of airway obstruction. Restlessness and stridor are earlier, and rales are unrelated.
Question 5 of 5
The nurse is caring for a client with cancer who is exhibiting signs and symptoms that death is near. The client's daughter says that she does not want her mother to receive morphine because it will hasten her death. What response by the nurse is most appropriate?
Correct Answer: C
Rationale: Morphine alleviates air hunger and anxiety in end-of-life care, improving comfort without necessarily hastening death, addressing the daughter’s concerns therapeutically.