NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 of 5
The nurse is preparing to administer blood to a client with anemia. Which signs and symptoms of transfusion reaction should the nurse monitor for during the first 30 minutes? Select all that apply.
Correct Answer: B, D, E
Rationale: Sudden hypertension, restlessness, confusion, jugular vein distension, low back pain, and impending doom indicate possible transfusion reactions (e.g., hemolytic or circulatory overload). Normal respiratory rate and oxygen saturation are not concerning.
Question 2 of 5
A trauma client is admitted to the emergency room following a motor vehicle accident. Examination reveals that the left side of the chest moves inward when the client inhales. The finding is suggestive of:
Correct Answer: D
Rationale: Inward chest movement on inhalation indicates flail chest, where multiple rib fractures cause a segment of the chest wall to move independently.
Question 3 of 5
While a dosage of oral morphine has approximately 25% bioavailability, what percentage is the bioavailability of an intravenous dose of morphine? Record your answer using a whole number.
Correct Answer: 100
Rationale: Intravenous morphine has 100% bioavailability, as it is delivered directly into the bloodstream, bypassing metabolism.
Question 4 of 5
The nurse is reviewing labs on a client receiving IV heparin and notes an INR of 4.6. Which order by the health care provider does the nurse anticipate?
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, appropriate for an elevated INR indicating excessive anticoagulation.
Question 5 of 5
A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
Correct Answer: C
Rationale: Addison's disease causes sodium loss and potassium retention, so monitoring sodium and potassium levels is essential during glucocorticoid therapy.