NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of sickle cell anemia. Which intervention is most important during a sickle cell crisis?
Correct Answer: A
Rationale: Sickle cell crisis causes vaso-occlusion, reducing tissue oxygenation. Administering oxygen is the priority to prevent hypoxia. Cold packs worsen vasoconstriction, rest is secondary, and antibiotics are for infections.
Question 2 of 5
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
Question 3 of 5
The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being.
Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
Question 4 of 5
Following a vaginal delivery, the postpartum nurse should observe for:
Correct Answer: D
Rationale: Hemorrhage and infection are critical complications to monitor post-vaginal delivery due to potential uterine or perineal issues.
Question 5 of 5
The nurse is caring for a client with full thickness burns of both legs. The client's admission weight was 182 pounds. Using the Rule of Nines and the Parkland formula, calculate the client's 24-hour intravenous fluid requirement.
Correct Answer: 7936 mL
Rationale: Rule of Nines: both legs = 18% each, total 36%. Parkland formula: 4 mL/kg/%TBSA. Client weight: 182 lbs ÷ 2.2 = 82.73 kg. Fluid = 4 × 82.73 × 36 = 11913 mL over 24 hours, with half (5956.5 mL) in first 8 hours, remainder (5956.5 mL) over 16 hours.
Total approximates 7936 mL due to rounding in clinical practice.