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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 16 )

Updated On: 12-Jan-2026
Page 16 of 345
PDF with 862 Questions

A 52-year-old client's abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration
for which she is especially at risk is:

  1. Air embolus
  2. Circulatory overload
  3. Hypocalcemia
  4. Hypokalemia

Answer(s): C

Explanation:

(A) Air embolism is a potential complication of blood administration, but it is fairly rare and can be prevented by using good IV technique. (B) Circulatory overload is a potential complication of blood administration, but because this client is actively bleeding, she is not at high risk for overload. (C) Hypocalcemia is a potential complication of blood administration that occurs in situations where massive transfusion has occurred over a short period of time. It occurs because the citrate in stored blood binds with the client's calcium. Another potential complication for which this client is especially at risk is hypothermia, which can be prevented by using a blood warmer to administer the blood. (D) Hypokalemia is not a complication of blood administration.



A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:

  1. Prone
  2. Supine
  3. Side lying
  4. Semi-Fowler

Answer(s): A

Explanation:

(A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to prevent trauma and infection of the sac. (B) The supine position exerts pressure on the sac. (C) Newborns usually cannot maintain side-lying position. (D) The semi- Fowler position exerts pressure on the sac.



A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?

  1. 1 mEq
  2. 1.13 mEq
  3. 2 mEq
  4. Not enough information to calculate

Answer(s): C

Explanation:

(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq. (D) Information is adequate for calculation.



A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:

  1. Anorexia nervosa
  2. Anorexia hysteria
  3. Bulimia
  4. Conversion reaction

Answer(s): C

Explanation:

(A) Anorexia nervosa is characterized by self-starvation. (B) Anorexia hysteria is not a known disease or disorder. (C) Bulimia is characterized by food binges and self-induced vomiting. (D) Conversion reaction is a defense mechanism.



A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:

  1. Digoxin (Lanoxin) 0.25 mg po every day
  2. Furosemide (Lasix) 40 mg po every morning
  3. O22 L/min via nasal cannula
  4. Nitroglycerin (Nitrol) 1 inch topically every 4 hours

Answer(s): A

Explanation:

(A) Digoxin is a cardiac glycoside given to clients in heart failure to improve their myocardial contractility. (B) Furosemide is a loop diuretic given to clients in heart failure to promote diuresis. (C) O2is given to clients in heart failure to increase oxygenation and to prevent or treat hypoxemia. (D) Nitroglycerin is a nitrate given to clients in heart failure to increase their cardiac output by decreasing the peripheral resistance that the left ventricle must pump against.



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