NCLEX-RN
NCLEX RN Practice Exam Questions
Extract:
Question 1 of 5
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
Question 2 of 5
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.
Question 3 of 5
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (
A) posing immediate risk to self or others. History of falls (
B), past violence (
C), or non-cooperation (
D) do not warrant restraints.
Question 4 of 5
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
Correct Answer:
Rationale:
Question 5 of 5
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which can exacerbate ischemia. The nurse should question the prescription.