NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a closed head injury. A late sign of increased intracranial pressure is:
Correct Answer: A
Rationale: Changes in pupil equality and reactivity are late signs of increased intracranial pressure, indicating neurological deterioration.
Question 2 of 5
The nurse is performing discharge teaching for a client after a cardiac catheterization. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Applying an ice bag for bleeding is incorrect; direct pressure should be applied, and the physician notified. This statement indicates a need for further teaching.
Question 3 of 5
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
Correct Answer: A
Rationale: Writing unverified suspicions of illegal drug use that are later seen by others constitutes libel, as it is a written defamatory statement.
Question 4 of 5
The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?
Correct Answer: A
Rationale: A trough level of 14 mcg/mL is within the therapeutic range (10–20 mcg/mL) for vancomycin, so the next dose can be given as ordered.
Question 5 of 5
The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:
Correct Answer: D
Rationale: Checking the site for bleeding ensures early detection of hematoma or excessive bleeding post-heparin injection.