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Questions 149

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

The nurse is caring for a client with a stage II sacral ulcer. Which nursing intervention would be most effective in promoting healing?

Correct Answer: C

Rationale: Increased protein and calorie intake supports tissue repair and healing for a stage II ulcer, more than heat lamps, antibiotics (unless infection is present), or wet-to-dry dressings.

Question 2 of 5

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:

Correct Answer: B

Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.

Question 3 of 5

A client with increased intracranial pressure is receiving Mannitol and Lasix. The nurse recognizes that these two drugs are given to reverse which effect?

Correct Answer: C

Rationale: Mannitol and Lasix are diuretics that reduce cerebral edema by drawing fluid out of swollen brain cells, decreasing intracranial pressure.

Question 4 of 5

A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by

Correct Answer: C

Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.

Question 5 of 5

The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?

Correct Answer: 60

Rationale: Concentration: 100 units/500 mL = 0.2 units/mL.
To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.

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