NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
Which of the following security concerns is also a sentinel event that must be reported?
Correct Answer: B
Rationale: The assisted suicide of a client is a sentinel event, as it is an unexpected occurrence involving death, requiring immediate investigation and reporting per The Joint Commission standards.
Question 2 of 5
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
Question 3 of 5
A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is:
Correct Answer: B
Rationale: Respondeat superior is Latin for 'The master is responsible for the acts of his servant'. The nurse, as an employee of the hospital, acted according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence, or tort law. (CN: Management of care; CL: Evaluate)
Question 4 of 5
The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
Correct Answer: B
Rationale: Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered.
Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
Question 5 of 5
A client with a history of chronic lymphocytic leukemia is prescribed rituximab (Rituxan). The nurse should monitor the client for which of the following side effects during infusion?
Correct Answer: C
Rationale: Rituximab can cause infusion reactions, such as fever or chills, requiring close monitoring during administration.