NCLEX RN· Full Length · Practice NCLEX RN Questions
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Showing all 10 practice questions with expert explanatory rationales.
A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
Expert Explanatory Rationale
Correct Answer: Demadex (torsemide)
Demadex, a loop diuretic, causes potassium loss, increasing the risk of hypokalemia, unlike potassium-sparing diuretics like Aldactone.
Which cephalic presentation is most common during delivery of a neonate?
Expert Explanatory Rationale
Correct Answer: Vertex
Vertex presentation (A), with the head flexed and occiput leading, is the most common (95%) during delivery.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
Expert Explanatory Rationale
Correct Answer: High fever
High fever is a hallmark of bacterial pneumonia due to the body's response to infection.
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO₂ 85, PCO₂ 55, and HCO3 27. These ABG values indicate that the client is in:
Expert Explanatory Rationale
Correct Answer: Compensated respiratory acidosis
pH 7.35 is normal, PCO₂ 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:
Expert Explanatory Rationale
Correct Answer: Stop the medication from infusing
Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
Expert Explanatory Rationale
Correct Answer:
Age, gender, and culture influence grief; nurses must process their own feelings to help others, and supporting families post-loss is key. Grief is not inherently detrimental, and expression should be encouraged.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
Expert Explanatory Rationale
Correct Answer: Produces a burning sensation when applied
Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.
The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?
Expert Explanatory Rationale
Correct Answer: The cavity likely contains fluid or pus.
Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.
A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
Expert Explanatory Rationale
Correct Answer: Wipe the chest dry with an available cloth or towel.
Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.
The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?
Expert Explanatory Rationale
Correct Answer: Coconut oil
Coconut oil is high in saturated fats, which raise LDL cholesterol, making it unsuitable for a low-cholesterol diet.
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