NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a complete cardiac and respiratory arrest. This client has little of no chance for survival and they are facing imminent death according to your professional judgement, knowledge of pathophysiology and your critical thinking. You believe that all life saving measures for this client would be futile. What is the first thing that you, as the nurse, should do?
Correct Answer: B
Rationale: The client's advance directive clearly states a desire for all life-saving measures, including CPR and advanced cardiac life support. Despite the nurse's professional judgment about futility, the nurse is legally and ethically obligated to follow the advance directive and initiate CPR immediately in the event of a cardiac and respiratory arrest. Notifying the doctor or family or ensuring comfort are secondary actions after initiating life-saving measures as per the client's documented wishes.
Question 2 of 5
A primigravid client at 38 weeks' gestation reports decreased fetal movement. What is the nurse's first action?
Correct Answer: D
Rationale: Auscultating fetal heart tones is the first step to assess fetal well-being in response to decreased movement, providing immediate data.
Question 3 of 5
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
Question 4 of 5
Which of the following clients is at greatest risk for extravasation?
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
Question 5 of 5
A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.