NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 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 2 of 5
A client in the recovery ICU is on mechanical ventilation. The nurse notices the client has frothy secretions around his mouth, and the nurse hears adventitious breath sounds with the stethoscope. The nurse should
Correct Answer: B
Rationale: Frothy secretions and adventitious sounds suggest airway obstruction or pulmonary edema. Suctioning clears the endotracheal tube, improving ventilation.
Question 3 of 5
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
Correct Answer: C
Rationale: Buck's traction is used to immobilize a fractured femur, reduce pain, and prevent further injury until surgical intervention.
Question 4 of 5
A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:
Correct Answer: A
Rationale: Acute adrenal crisis causes low blood pressure due to insufficient cortisol and aldosterone, leading to hypovolemia and shock.
Question 5 of 5
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D). Which of the following actions by the nurse is MOST appropriate?
Correct Answer: B
Rationale: medication is very irritating to subcutaneous tissue