NCLEX-RN
NCLEX-RN Exam Questions
Extract:
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.