RN NCLEX Practice Questions
Question 1 of 5.
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
A. Assess for signs of abnormal bleeding
B. Anticipate an increase in the heparin drip rate
C. Instruct the client regarding the drug therapy
D. Increase the frequency of vascular assessments
Explanation: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
Question 2 of 5.
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
A. Irrigate the nasogastric tube with distilled water.
B. Aspirate the gastric contents with a syringe.
C. Administer an antiemetic medicine.
D. Insert a new nasogastric tube.
Explanation: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
Question 3 of 5.
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to
A. withhold the medication.
B. decrease the dose by half.
C. administer the medication.
D. wait 15 minutes, then recheck the rate.
Explanation: maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
Question 4 of 5.
The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks. The nurse would be MOST concerned if the mother made which of the following statements?
A. My son plays the tuba in the grade school band.
B. My son loves to help his dad rake leaves.
C. My son participates in after-school activities three days a week.
D. My son walks one mile to school every day with his friends.
Explanation: main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves
Question 5 of 5.
The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
A. Abdominal discomfort during infusion of dialysate.
B. Presence of constipation.
C. Cloudy dialysate output.
D. Ecchymosis around peritoneal catheter.
Explanation: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity