NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The therapeutic blood-level range for lithium is:
Correct Answer: B
Rationale: This range is too low to be therapeutic. This is the therapeutic range for lithium. This range is above the therapeutic level. This range is toxic and may cause severe side effects.
Question 2 of 5
The nurse is caring for a client who is receiving oxytocin for labor induction. The fetal heart rate shows variable decelerations. The nurse’s first action should be to:
Correct Answer: B
Rationale: Variable decelerations suggest umbilical cord compression. Repositioning the client (e.g. to the left side or knee-chest position) may relieve compression and is the first action. Stopping oxytocin or notifying the physician may be needed if repositioning is ineffective.
Question 3 of 5
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
Correct Answer: C
Rationale: Ampicillin is a safe antibiotic for pyelonephritis in pregnancy, with no known teratogenic effects.
Question 4 of 5
The nurse is caring for a client with a history of a spinal fusion. The client complains of back pain. The nurse should:
Correct Answer: D
Rationale: Back pain post-spinal fusion may indicate complications like hardware failure or infection, requiring immediate physician notification. Compresses, rest, and acetaminophen are insufficient.
Question 5 of 5
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel decompression. When preparing to insert a NG tube, the nurse measures from the:
Correct Answer: D
Rationale: This measurement is ~50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement is ~50 cm (47-48 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-ear-xiphoid). This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.