NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
Which anatomical site and method should the nurse use to administer an injection of iron to a client?
Correct Answer: B
Rationale: The correct technique for administering parenteral iron is deep in the gluteal muscle using Z-track technique to minimize the possibility of staining or irritating the tissues. Administering iron subcutaneously or with a short needle and using the deltoid muscle is contraindicated because of iron's irritating nature.
Question 2 of 5
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value should the nurse most likely expect to note?
Correct Answer: A
Rationale: Extensive burns covering greater than 25% of the TBSA result in generalized body edema in both burned and nonburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels elevate in the first 24 hours after injury (the emergent phase) as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit is 42 to 52% (0.42-0.52) in the male and 37 to 47% (0.37-0.47) in the female. The normal albumin is 3.5-5 g/dL (35-50 g/L). The normal sodium level is 135 to 145 mEq/L (135-145 mmol/L). The normal WBC count is 5000 to 10,000 mm^3 (5-10 x 10^9/L).
Question 3 of 5
The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?
Correct Answer: A
Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.
Question 4 of 5
A client with alcohol dependence states, 'I feel so bad because of what I've done to my wife and kids. I'm just no good.' Which of the following responses by the nurse is most appropriate?
Correct Answer: C
Rationale: Framing alcohol dependence as a treatable disease offers hope and reduces self-blame, supporting recovery. Other responses may reinforce guilt or are less therapeutic.
Question 5 of 5
While assessing the psychosocial aspects of a primigravid client at 30 weeks' gestation, which of the following feelings are expected?
Correct Answer: C
Rationale: Ambivalence is common in pregnancy, reflecting mixed emotions about impending motherhood and life changes.