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 is admitted to the hospital in chronic renal failure. A low protein diet is ordered. The rationale for a low protein diet is that:
Correct Answer: A
Rationale: In chronic renal failure, a low protein diet reduces the production of nitrogenous wastes like blood urea nitrogen (BUN), easing the kidneys’ workload. It does not directly affect sodium, potassium, albumin, calcium, or phosphorus levels.
Question 3 of 5
The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:
Correct Answer: B
Rationale: A blood alcohol level of 460 mg/dL (0.46%) is life-threatening and can cause respiratory depression, a critical concern requiring close monitoring. Coordination loss and tachycardia are less immediate.
Question 4 of 5
A 26-year-old client is diagnosed with an astrocytoma, a benign brain tumor. From the nurse's knowledge of the central nervous system, the nurse knows that benign tumors:
Correct Answer: A
Rationale: Both a benign and a malignant tumor can displace or destroy nearby structures or increase intracranial pressure.
Question 5 of 5
The nurse is caring for a client with a history of a fractured pelvis who is in skeletal traction. The nurse should:
Correct Answer: D
Rationale: Monitoring for infection at pin sites prevents osteomyelitis in skeletal traction. Turning is limited, weights must hang freely, and lotion is unnecessary.