NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
Correct Answer: D
Rationale: Remaining with the client for at least 15-30 minutes after starting a blood transfusion is critical to monitor for acute transfusion reactions, such as hemolytic or allergic reactions.
Question 2 of 5
The nurse is caring for a client with a history of Crohn's disease who is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: C
Rationale: Fever may indicate an exacerbation of Crohn's disease or a side effect of mesalamine, requiring immediate reporting.
Question 3 of 5
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.
Question 4 of 5
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, should the nurse monitor the client for?
Correct Answer: B
Rationale: Heparin sodium is an anticoagulant. The client who receives heparin sodium is at risk for bleeding. The nurse monitors for signs of bleeding, which includes bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The remaining options are not related side or adverse effects of this medication.
Question 5 of 5
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.