NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
Question 2 of 5
What is the purpose of administering diphenhydramine before a blood transfusion?
Correct Answer: A
Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.
Question 3 of 5
Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client?
Correct Answer: D
Rationale:
Total bilirubin of 17 umol/L (1 mg/dL) is elevated (normal 0.1-1.0 mg/dL), indicating potential liver or biliary issues, requiring reporting.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
Question 5 of 5
A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the neck. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.