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Questions 148

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin:

Correct Answer: B

Rationale: Nitroglycerin dilates coronary blood vessels, improving blood flow to the myocardium and relieving angina.

Question 2 of 5

Which of the following actions does NOT require the use of standard precautions?

Correct Answer: C

Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.

Question 3 of 5

The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.

Question 4 of 5

A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.

Order the Items

Source Container

attach the flush syringe and flush catheter with normal saline
stop the infusion and disconnect Ringer's lactate
withdraw a blood sample and discard
scrub the catheter hub
withdraw the blood sample for the lab

Correct Answer: B,D,C,A,E

Rationale: Order: Stop infusion (
B), scrub hub (
D), withdraw/discard blood (
C), flush with saline (
A), withdraw lab sample (E). This ensures a clean, accurate sample.

Question 5 of 5

A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?

Correct Answer: C

Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (
C), such as a loose connection or hole in the tubing. A pneumothorax (
A) may cause intermittent bubbling, adequate suction (
B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (
D) would not typically cause continuous bubbling.

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