NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 2 of 5
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
Question 3 of 5
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
Question 4 of 5
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
Correct Answer: B
Rationale: Aminophylline, a bronchodilator, is effective when it relaxes bronchial smooth muscles, improving airflow in emphysema.
Question 5 of 5
Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?
Correct Answer: C
Rationale: Thorough hand washing is the most effective measure to prevent the spread of bacterial conjunctivitis.