NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to administer heparin to a client with a deep vein thrombosis. Which of the following laboratory values should the nurse check before administering the dose?
Correct Answer: B
Rationale: heparin’s therapeutic effect is monitored by aPTT, which should be 1.5–2 times the control value
Question 2 of 5
A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning the client promotes blood circulation, which enhances tissue perfusion and prevents pressure ulcers. Assessing the skin detects problems but doesn't improve perfusion, massaging erythematous areas can worsen tissue damage, and changing pads addresses hygiene but not perfusion directly.
Question 3 of 5
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
Question 4 of 5
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
Correct Answer: C
Rationale: Cucumber salad contains seeds and roughage, which can irritate the colon in diverticulosis and should be avoided.
Question 5 of 5
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
Correct Answer: A
Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (
A). Cognitive impairment (
B), vision impairment (
C), and anxiety (
D) do not typically present with these specific behaviors.