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

Questions 158

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Question 1 of 5

The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

Correct Answer: D

Rationale: Discussing organ donation with the wife while the client is still alive may cause distress, especially given her opposition. The nurse should refrain from raising the topic until after the client’s death, respecting her emotional state and hospital policy, which typically involves organ donation teams post-mortem.

Question 2 of 5

The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?

Correct Answer: C

Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.

Question 3 of 5

The physician has prescribed Oxycontin (oxycodone) for a client following an exploratory laparotomy. Which of the following is an adverse effect associated with the medication?

Correct Answer: C

Rationale: Oxycontin, an opioid, can cause nervousness or restlessness as a central nervous system side effect, alongside more common effects like sedation or respiratory depression. Pulmonary edema, increased blood pressure, and rapid pulse are not typical.

Question 4 of 5

Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.

Order the Items

Source Container

Suction the oral cavity.
Auscultate breath sounds for effectiveness.
Set suction control at 80-120 mm Hg.
Ambu or oxygenate at 100% O2
Apply suction while withdrawing the suction catheter.
Turn the head toward the side to be suctioned.
Auscultate breath sounds prior to suctioning.

Correct Answer: G, C, D, F, E, B, A

Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (
C), oxygenate (
D), turn head (F), apply suction (E), auscultate post-suction (
B), suction oral cavity (
A) to clean.

Question 5 of 5

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:

Correct Answer: A

Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.

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