NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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NCLEX Practice Test RN Questions

Extract:


Question 1 of 5

The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?

Correct Answer: A

Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (
B) is expected, nausea/vomiting (
C) are common, and BUN/skin changes (
D) are less urgent.

Question 2 of 5

A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:

Correct Answer: A

Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.

Question 3 of 5

The nurse is caring for a client with a suspected fractured hip. Which intervention is most appropriate?

Correct Answer: C

Rationale: Immobilizing the leg prevents further injury and displacement in a suspected hip fracture. Amb

Question 4 of 5

The nurse is preparing to administer a dose of penicillin to a client with a streptococcal infection. Which assessment is most important before administration?

Correct Answer: A

Rationale: Penicillin has a high risk of allergic reactions, including anaphylaxis. Assessing allergy history is critical before administration. Vital signs are monitored but are less specific to penicillin risks.

Question 5 of 5

Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?

Order the Items

Source Container

Circle the surgical site with a marker.
Verify patient information with a designated patient representative.
Designate operative site with a facility designated mark.
Include a copy of the Advanced Directives on the chart before surgery.
Verify patient information three times.
Observe pre-op time out before proceeding with surgery.

Correct Answer: C, E, F

Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.

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