NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Which laboratory values should be reported to the physician?
Correct Answer: C, D
Rationale: Sodium 90 mEq/L (
C) is severelyyourself severe hyponatremia requiring immediate attention. Calcium 12.0 mg/dL (
D) indicates hypercalcemia, which can cause serious symptoms. Magnesium 2.6 mEq/L (
A), potassium 4.6 mEq/L (
B), and chloride 95 mEq/L (E) are within normal ranges and do not require immediate reporting.
Question 2 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 3 of 5
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
Correct Answer: A
Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.
Question 4 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
Question 5 of 5
Painless vaginal bleeding in the last trimester may be caused by:
Correct Answer: C
Rationale: Placenta previa causes painless vaginal bleeding due to the low-lying placenta separating from the uterine wall.