NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
Which of the following techniques is correct when administering a subcutaneous injection?
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.
Question 2 of 5
How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL
Correct Answer: A
Rationale:
To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.
Question 3 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
Question 4 of 5
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.
Question 5 of 5
What condition should the nurse assess a client diagnosed with pernicious anemia for? Select all that apply.
Correct Answer: A,E
Rationale: Classic clinical indicators of pernicious anemia include weakness; mild diarrhea; and a smooth, sore, red tongue. The client may also have neurological findings, such as paresthesias, confusion, and difficulty with balance. Constipation is not a common finding with pernicious anemia. Pernicious anemia does not affect tissue oxygenation, so the mucous membranes do not become dusky, and the client does not exhibit shortness of breath.