NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature (
B) is important but secondary, low hematocrit (
C) is not a goal, and 300 mL/hr urine output (
D) is excessive.
Question 2 of 5
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
Correct Answer: B
Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.
Question 3 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?
Correct Answer: A
Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.
Question 4 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 5 of 5
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
Correct Answer: B
Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.