NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The sputum of a client remains positive for the tubercle bacillus even though the client has been taking Laniazid (isoniazid) in combination with other antituberculars. The nurse recognizes that the client taking isoniazid should have a negative sputum culture within:
Correct Answer: D
Rationale: Effective antitubercular therapy, including isoniazid, typically results in a negative sputum culture within three months, indicating control of active infection.
Question 2 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 3 of 5
A client being treated with sodium warfarin (Coumadin) has a prothrombin time of 120 seconds. The nurse recognizes that:
Correct Answer: A
Rationale: A prothrombin time of 120 seconds is excessively prolonged indicating a high bleeding risk. Close monitoring for bleeding (e.g. bruising hematuria) is critical. The dosage is not inadequate vitamin K restriction is routine and doubling doses is dangerous.
Question 4 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 5 of 5
The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?
Correct Answer: C
Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.