NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
Question 2 of 5
The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse suspects hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock?
Correct Answer: A, B, D
Rationale: Hypovolemic shock involves low blood volume, reflected by low hemoglobin (5 g,
A), low central venous pressure (2 mmHg,
B), and low hematocrit (22%,
D). Normal pulmonary artery wedge pressure (16 mmHg,
C) suggests no left heart failure. Elevated troponin (E) indicates myocardial damage, not volume status.
Question 3 of 5
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
Correct Answer: A
Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.
Question 4 of 5
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
Correct Answer: B
Rationale: It is sufficient to rinse the plastic holders with warm water at least once per day. It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. 'Neutralizing' the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.
Question 5 of 5
What is the appropriate nursing action for a child with increased intracranial pressure?
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.