NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C,
D) These values are incorrect.
Question 2 of 5
A client with a history of a seizure disorder is receiving Phenobarbital. The nurse should teach the client to:
Correct Answer: A
Rationale: Alcohol can interact with phenobarbital, increasing sedation or reducing seizure control. Meals, calcium, and weight gain are not primary concerns.
Question 3 of 5
A 35-year-old client has returned to her room following surgery on her right femur. She has an IV of D5 in one-half normal saline infusing at 125 mL/hr and is receiving morphine sulfate 10-15 mg IM q4h prn for pain. She last voided 5-1/2 hours ago when she was given her preoperative medication. In monitoring and promoting return of urinary function after surgery, the nurse would:
Correct Answer: C
Rationale: Provision of food and fluid promotes bowel elimination. Nutritional needs postoperatively are determined by the physician, not the client. Increasing IV fluids postoperatively will not cause a client to void. Any change in rate of administration of IV fluids should be determined by the physician. The postoperative client with normal kidney function who cannot void 8 hours after surgery is retaining urine. The client may need catheterization or medication. The physician must provide orders for both as necessary. Although morphine sulfate can cause urinary retention, withholding pain medication will not ensure that the client will void. The client with uncontrolled pain will probably not be able to void.
Question 4 of 5
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
Question 5 of 5
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (
A), drowsiness (
C), and flatulence (
D) are expected.