NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
Correct Answer: D
Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.
Question 2 of 5
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
Correct Answer: B
Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.
Question 3 of 5
The nurse is caring for a client with a history of a fractured ankle who is in a cast. The client complains of numbness and tingling. The nurse should:
Correct Answer: C
Rationale: Numbness and tingling suggest neurovascular compromise (e.g., compartment syndrome), requiring immediate physician notification. Ice, elevation, and massage are insufficient.
Question 4 of 5
The nurse is caring for a client with a diagnosis of placenta previa. Which intervention is most appropriate?
Correct Answer: A
Rationale: Placenta previa requires bedrest to minimize bleeding risk by reducing cervical pressure.
Tocolytics are not typically used vaginal delivery is contraindicated and antibiotics are not indicated unless infection is present.
Question 5 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.