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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 40 )

Updated On: 12-Jan-2026
Page 40 of 345
PDF with 862 Questions

A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:

  1. Take a baseline set of vital signs
  2. Hang Ringer's lactate as the companion fluid
  3. Use microdrip tubing for the blood administration
  4. Have the registered nurse in charge assume responsibility for verifying the client and blood product information

Answer(s): A

Explanation:

(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.



A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:

  1. Fresh vegetables and fruit
  2. Canned vegetables and fruit
  3. Breads, cereals, and rice
  4. Fish

Answer(s): B

Explanation:

(A) Fresh vegetables and fruits are excellent sources of essential vitamins. (B) Canned and frozen foods have a high sodium content. Labels of all canned foods should be read to determine if sodium is used in any form. (C) Bread, cereal, and rice are excellent sources of carbohydrates. (D) Fish is an excellent source of protein.



An expected response to sodium polystyrene sulfonate (Kayexalate) is:

  1. Increase in serum magnesium
  2. Increase in serum HCO3
  3. Decrease in serum potassium
  4. Decrease in serum calcium

Answer(s): C

Explanation:

(A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.



A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

  1. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
  2. Advise the client to discontinue the drug at the first sign of dizziness.
  3. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
  4. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.

Answer(s): A

Explanation:

(A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.



A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?

  1. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness
  2. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow
  3. Potential for injury related to impaired mobility and seizures
  4. Impaired verbal communication related to aphasia

Answer(s): A

Explanation:

(A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.



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