NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
Correct Answer: B
Rationale: This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. Sexual infantilism is characteristic of this syndrome. Gynecomastia is a symptom in Klinefelter's syndrome.
Question 2 of 5
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.
Question 3 of 5
A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24 hour period?
Correct Answer: 720
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units/dose. Frequency: every 4 hours = 6 doses/day.
Total: 120 × 6 = 720 units.
Question 4 of 5
A female client with major depression stated that 'life is hopeless and not worth living.' The nurse should place highest priority on which of the following questions?
Correct Answer: B
Rationale: Maintenance of the client's life is the priority; assessment of suicidal intent is imperative.
Question 5 of 5
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
Correct Answer: A
Rationale: This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B,
C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. This answer is incorrect.
Toxic poisoning is usually at the 2.0 level or higher.