NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
To protect a client who has received tissue plasminogen activator (t-PA, or Activase) therapy, the nurse should:
Correct Answer: B
Rationale: Maintaining pressure on arterial puncture sites for 10 seconds minimizes bleeding risk, critical after t-PA due to its thrombolytic effects.
Question 2 of 5
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
Question 3 of 5
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.
Question 4 of 5
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
Question 5 of 5
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.