NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.
Question 2 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
Question 3 of 5
A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
Question 4 of 5
A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Costovertebral tenderness is a hallmark of pyelonephritis, indicating kidney involvement, unlike the other symptoms, which are more typical of cystitis.
Question 5 of 5
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals is most appropriate for the nurse to emphasize?
Correct Answer: D
Rationale: Regular blood pressure monitoring empowers clients to track their hypertension and adjust lifestyle or medication as needed.