NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to hang a unit of blood on a client. The blood has been checked off with two RNs and the pre-infusion vitals recorded. The nurse is at the bedside monitoring the infusion. Shortly after beginning the infusion, the pump alarm sounds. The IV has infiltrated. No blood has yet reached the client. The client is a hard stick, and the nurse realizes that a line cannot be placed within the time frame to begin the infusion. Which action by the nurse is correct?
Correct Answer: C
Rationale: Since no blood reached the client and IV access cannot be re-established within the time frame, the nurse should cancel the order and notify the provider to reassess the need for transfusion.
Question 2 of 5
A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
Question 3 of 5
The nurse answers a call to the unit, which turns out to be a bomb threat. Which actions by the nurse are correct? Select all that apply.
Correct Answer: B, D
Rationale: Following protocol and alerting authorities ensure safety and proper response, while dismissing the threat or evacuating without orders is unsafe.
Question 4 of 5
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
Question 5 of 5
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.