NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

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Extract:


Question 1 of 5

When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:

Correct Answer: D

Rationale: At 32 weeks gestation, the fetus is active, and Leopold maneuvers should detect active fetal movement as the fetus is well-developed and mobile.

Question 2 of 5

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?

Correct Answer: B

Rationale: Hypotension and tachycardia suggest shock, requiring immediate physician notification.

Question 3 of 5

The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?

Correct Answer: A

Rationale: A trough level of 14 mcg/mL is within the therapeutic range (10–20 mcg/mL) for vancomycin, so the next dose can be given as ordered.

Question 4 of 5

After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

Correct Answer: C

Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.

Question 5 of 5

A client with burns is admitted and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours; the client's CVP reading is 14 cm/Hâ‚‚O. Which evaluation by the nurse would be most accurate?

Correct Answer: D

Rationale: A CVP of 14 cm/Hâ‚‚O (normal: 3-8 cm/Hâ‚‚O) indicates fluid volume excess, likely from aggressive resuscitation, requiring careful monitoring to prevent complications.

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