NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Which action by the home health nurse indicates a knowledge of the needs of an elderly client?
Correct Answer: D
Rationale: Fall prevention is a critical need for elderly clients due to risks of injury from reduced mobility or balance. Hospice teaching is premature, high-pitched speech may not aid hearing, and fluid restriction can cause dehydration.
Question 2 of 5
The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:
Correct Answer: C
Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.
Question 3 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?
Correct Answer: A
Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.
Question 4 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
Question 5 of 5
A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:
Correct Answer: A
Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.