NCLEX-RN Practice Test #12 2

Question 1

The RN is supervising a nursing team of one LPN and one nursing assistant (NA). Which task is appropriate to delegate to the LPN?

Accepted Answer

Administer a scheduled oral medication to a stable post-op client

Answer

Perform the initial nursing assessment for a newly admitted client

Answer

Develop the nursing care plan for a client with a complex wound

Answer

Evaluate the client's understanding of discharge teaching

Question 2

A client with sepsis meets SIRS criteria: HR 118, RR 26, temperature 38.8°C, WBC 14,000. The nurse is implementing the Sepsis Hour-1 Bundle. Which intervention is the priority first step?

Accepted Answer

Obtain blood cultures × 2 from two different sites before antibiotics

Answer

Administer broad-spectrum antibiotics within 3 hours

Answer

Measure a serum lactate level

Answer

Initiate a norepinephrine infusion for blood pressure support

Question 3

An RN is working in the medical-surgical unit. Which client situation requires the RN to perform the assessment personally rather than accepting the LPN's report?

Accepted Answer

A client who has developed new onset confusion, declining blood pressure, and increased respiratory rate within the past hour

Answer

A stable client post-op day 3 who has resumed oral intake

Answer

A client receiving continuous telemetry for stable atrial fibrillation

Answer

A client with a known diagnosis of COPD on 2 L/min O₂ with stable SpO₂ 91%

Question 4

A client with heart failure is receiving IV furosemide. Which set of assessment findings most clearly indicates a therapeutic response?

Accepted Answer

Urine output 800 mL over 4 hours, weight decreased 1.2 kg from admission, SpO₂ improved to 97%, crackles diminished

Answer

Urine output of 40 mL/hour, unchanged weight, SpO₂ 93%

Answer

Blood pressure decreased to 90/60 mmHg with urine output 30 mL/hour

Answer

Edema unchanged at 4+ bilateral with UO of 60 mL/hour

Question 5

The RN is caring for a client who is a DNR (Do Not Resuscitate). The client becomes unresponsive. The client's adult child arrives and demands that CPR be initiated. How should the RN respond?

Accepted Answer

Explain compassionately that the DNR represents the client's own documented wishes and reflects the highest standard of care; involve palliative care and the attending physician

Answer

Initiate CPR as the family has override authority over the DNR order

Answer

Consult with the charge nurse and delay any action until the dispute is resolved

Answer

Ask the client's child to sign a form rescinding the DNR before taking any action

Question 6

A client is post-operative day 1 after a bowel resection and has a nasogastric tube to low continuous suction. The client's serum potassium is 2.8 mEq/L and sodium is 128 mEq/L. These electrolyte imbalances are most likely caused by:

Accepted Answer

Continuous NG suction removing potassium and sodium in gastric secretions, combined with restriction of oral intake

Answer

Post-operative fluid redistribution into the third space only

Answer

Excessive IV fluid administration causing dilutional hyponatremia

Answer

Surgical blood loss leading to electrolyte depletion