NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response.
To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.
Question 2 of 5
A postpartum client is experiencing heavy lochia 3 days after delivery. Which action should the nurse take first?
Correct Answer: A
Rationale: Heavy lochia may indicate uterine atony. Massaging the fundus is the first step to promote uterine contraction and reduce bleeding before escalating to other interventions.
Question 3 of 5
Which of the following data points about your client's hemodynamic values would you report to the doctor as abnormal?
Correct Answer: B
Rationale: Normal ranges are: PAS 15-30 mmHg, PAWP 4-12 mmHg, PAD 4-12 mmHg, CVP 2-6 mmHg. PAWP of 22 mmHg is elevated, indicating potential left ventricular dysfunction or fluid overload.
Question 4 of 5
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
Question 5 of 5
Which federal law is most closely associated with the highly restrictive 'need to know'?
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPA
A) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.