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
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
Correct Answer: C
Rationale: A multi-lumen tunneled and cuffed central venous catheter is ideal for long-term therapy due to its durability and lower infection risk.
Question 3 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 4 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Question 5 of 5
A woman is taking oral contraceptives. The nurse teaches the client that medications that may interfere with oral contraceptive efficacy include:
Correct Answer: B
Rationale: Certain antibiotics (e.g., rifampin) can reduce oral contraceptive efficacy by altering gut flora, affecting hormone absorption.