NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 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 2 of 5
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.
Question 3 of 5
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
Question 4 of 5
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
Correct Answer: A
Rationale: Clear, simple instructions with eye contact and repetition enhance communication for a child with ADHD, and praise reinforces positive behavior.
Question 5 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.