NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. Following mitral valve replacement surgery, a client develops PVCs. The healthcare provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. The IV solution contains 2 grams of Lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate would deliver 4 mg of Lidocaine per minute?
- A. 60 microdrops/minute
- B. 20 microdrops/minute
- C. 30 microdrops/minute
- D. 40 microdrops/minute
Correct answer: A
Rationale: To calculate the rate needed to deliver 4 mg/minute of Lidocaine, first, convert 2 grams to milligrams: 2 grams = 2000 mg. Then, set up a ratio between the total amount of Lidocaine (2000 mg) and the total volume of IV solution (500 mL): 2000 mg / 500 mL = 4 mg / x mL. Solving for x, x = 1 mL. Since the infusion pump delivers 60 microdrops per mL, multiplying by 60 microdrops/mL gives the correct rate of 60 microdrops/minute. This rate ensures the desired 4 mg of Lidocaine is delivered per minute. Choices B, C, and D are incorrect as they do not align with the accurate calculation based on the provided information.
2. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
- A. Norplant is safe and can be easily removed.
- B. Oral contraceptives should not be used by smokers.
- C. Depo-Provera is convenient with few side effects.
- D. The IUD provides protection against pregnancy and infection.
Correct answer: B
Rationale: The correct answer is that oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases the risk of cardiovascular problems, such as thromboembolic disorders. This is due to the combined effect of smoking and hormonal contraceptives. Choices A, C, and D are incorrect because they do not address the specific risk associated with smoking and oral contraceptives. Norplant's safety and ease of removal, Depo-Provera's convenience with few side effects, and the IUD's protection against pregnancy and infection are important points but not directly related to the increased risks for smokers using oral contraceptives.
3. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
- A. Altered tissue perfusion
- B. Risk for fluid volume deficit
- C. High risk for hemorrhage
- D. Risk for infection
Correct answer: D
Rationale: The correct answer is 'Risk for infection.' When the membranes are ruptured for more than 24 hours prior to birth, there is a significantly increased risk of infection for both the mother and the newborn. Monitoring for signs of infection, such as fever, foul-smelling vaginal discharge, and uterine tenderness, is crucial. Option A, 'Altered tissue perfusion,' is not the priority in this scenario as infection risk takes precedence due to the prolonged rupture of membranes. Option B, 'Risk for fluid volume deficit,' is less of a priority compared to the immediate risk of infection. Option C, 'High risk for hemorrhage,' is not the priority concern at this time based on the information provided.
4. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct answer: A
Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.
5. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
- A. Confusion
- B. Loss of half of the visual field
- C. Shallow respirations
- D. Tonic-clonic seizures
Correct answer: C
Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99