NCLEX-RN Practice Questions with Nurse Brennan

Question 1: A nurse is caring for an elderly patient with pneumonia. Which assessment finding requires the most immediate intervention?

A. Temperature of 101°F (38.3°C)

B. Peripheral capillary oxygen saturation (SpO2) level of 88%

C. Mildly productive cough

D. Heart rate of 92 beats per minute

Correct Answer: B. Peripheral capillary oxygen saturation (SpO2) level of 88%

Rationale: An SpO2 level of 88% indicates significant hypoxemia and requires immediate intervention to improve oxygenation and prevent further complications. Supplemental oxygen should be administered as per protocol or physician order. The other findings may require attention but are not as immediately life-threatening.

Question 2: A client who has been prescribed digoxin presents with nausea, vomiting, and visual disturbances. What should the nurse do first?

A. Check the client's apical pulse

B. Hold the next dose of digoxin

C. Administer an antiemetic

D. Draw a blood sample for digoxin levels

Correct Answer: A. Check the client's apical pulse

Rationale: The nurse should first assess the client's apical pulse before administering any further doses of digoxin. Nausea, vomiting, and visual disturbances can be signs of digoxin toxicity, and the apical pulse is critical to evaluate, as a lower rate can also indicate toxicity. If the pulse is below 60 beats per minute, the next dose should be held, and further assessments, including digoxin level testing, should be conducted.

Question 3: An adolescent client with type 1 diabetes is learning to self-administer insulin. Which statement indicates that the client understands the teaching?

A. "I will inject my insulin in the same spot each day."

B. "I will avoid exercising after taking my insulin."

C. "I will check my blood sugar before administering insulin."

D. "I will use the same needle for two doses to save resources."

Correct Answer: C. "I will check my blood sugar before administering insulin."

Rationale: Checking blood sugar before administering insulin allows the client to adjust the insulin dose according to their current blood glucose level. Rotating injection sites is important to prevent lipodystrophy, and injecting in the same spot repeatedly can cause tissue damage. Exercise is encouraged but should be planned around insulin action times to prevent hypoglycemia. Using a new, sterile needle for each injection is crucial to prevent infection and ensure proper dosing.

Question 4: A patient with a history of heart failure is taking spironolactone. During a follow-up visit, which laboratory finding should the nurse report to the healthcare provider immediately?

A. Serum sodium level of 138 mEq/L

B. Serum potassium level of 6.2 mEq/L

C. Serum creatinine level of 1.0 mg/dL

D. Blood urea nitrogen (BUN) level of 15 mg/dL

Correct Answer: B. Serum potassium level of 6.2 mEq/L

Rationale: Spironolactone is a potassium-sparing diuretic, and a serum potassium level of 6.2 mEq/L indicates hyperkalemia, a potentially dangerous condition. Hyperkalemia can lead to cardiac arrhythmias and requires immediate attention. The other laboratory values are within normal range and not as immediately concerning as the elevated potassium level.

Question 5: A nurse is planning care for a client with impaired mobility due to a stroke. Which intervention should be included to prevent complications related to immobility?

A. Encourage a high-calcium diet

B. Limit fluid intake

C. Implement passive range-of-motion exercises

D. Place the client in a high Fowler's position

Correct Answer: C. Implement passive range-of-motion exercises

Rationale: Passive range-of-motion exercises are crucial in preventing complications related to immobility, such as joint contractures, muscle atrophy, and circulatory issues. While a high-calcium diet is important, especially for bone health, and positioning can aid with respiratory function, exercise is directly related to preventing immobility complications. Fluid intake should not necessarily be limited without specific indications.

Question 6: A client with tuberculosis (TB) is prescribed rifampin. What important side effect should the nurse inform the client about?

A. Hypertension

B. Red-orange discoloration of body fluids

C. Increased appetite

D. Hearing loss

Correct Answer: B. Red-orange discoloration of body fluids

Rationale: Rifampin can cause a harmless red-orange discoloration of body fluids, including urine, sweat, saliva, and tears. It's important to inform the client about this side effect to prevent alarm. The other options are not typical side effects of rifampin.