NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
Question 2 of 5
The nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician?
Correct Answer: D
Rationale: Capillary refill of 5 seconds indicates poor perfusion in a newborn, requiring physician notification.
Question 3 of 5
A client with a history of heart failure is admitted with pulmonary edema. The nurse should administer which of the following medications as prescribed? Select all that apply.
Correct Answer: A, C, D
Rationale: Furosemide reduces fluid overload, nitroglycerin decreases preload, and morphine relieves anxiety and preload in pulmonary edema.
Question 4 of 5
After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
Correct Answer: C
Rationale: Increasing frequency suggests tolerance; switching to an equianalgesic dose of morphine may provide better pain control without escalating doses.
Question 5 of 5
A child diagnosed with tinea is being treated with griseofulvin (Grifulvin V). Which of the following instructions should the nurse give to the parents?
Correct Answer: B
Rationale: Griseofulvin increases photosensitivity, so avoiding intense sunlight is critical. It is typically taken with food, requires weeks of treatment, and fluid intake is not specifically needed.