NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
Correct Answer: C
Rationale: These tests assess bleeding risk, critical before administering thrombolytics like alteplase, which can cause hemorrhage.
Question 2 of 5
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
Correct Answer: C
Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.
Question 3 of 5
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
Question 4 of 5
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
Question 5 of 5
A client with a history of type 2 diabetes is prescribed sitagliptin (Januvia). The nurse should instruct the client to:
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, requiring monitoring for abdominal pain.