NCLEX Questions, NCLEX-RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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NCLEX-RN Test Bank

NCLEX-RN Exam Questions

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Question 1 of 5

The nurse is caring for a client post-appendectomy. Which finding requires immediate intervention?

Correct Answer: B

Rationale: A temperature of 101.5°F post-appendectomy suggests infection (e.g., abscess), requiring immediate intervention. Pain (
A), serous drainage (
C), and absent bowel sounds (
D) are expected initially.

Question 2 of 5

The client is admitted with a diagnosis of septic shock. Which intervention is the priority?

Correct Answer: A

Rationale: In septic shock, administering IV antibiotics within the first hour is the priority to target the infection causing shock. Vasopressors, catheterization, and cultures are secondary.

Question 3 of 5

A female client with major depression stated that 'life is hopeless and not worth living.' The nurse should place highest priority on which of the following questions?

Correct Answer: B

Rationale: Maintenance of the client's life is the priority; assessment of suicidal intent is imperative.

Question 4 of 5

A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

Correct Answer: C

Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.

Question 5 of 5

After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:

Correct Answer: A

Rationale: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.

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