RN NCLEX-RN 2 — Questions and Answers
Question 1: A nurse is caring for a client with chronic kidney disease (CKD) who has a potassium level of 6.2 mEq/L. Which dietary instruction is most important?
- Increase intake of bananas and oranges
- Avoid foods high in potassium such as potatoes and tomatoes (Correct answer)
- Increase fluid intake to dilute serum potassium
- Consume high-protein foods to bind potassium
Correct answer: Avoid foods high in potassium such as potatoes and tomatoes
Hyperkalemia in CKD requires restricting high-potassium foods like potatoes, tomatoes, and bananas to prevent life-threatening cardiac arrhythmias.
Question 2: A postoperative client develops a respiratory rate of 6 breaths/min and is difficult to arouse after receiving IV morphine. What is the priority nursing action?
- Administer supplemental oxygen via face mask
- Notify the physician immediately
- Administer naloxone (Narcan) as ordered (Correct answer)
- Reposition the client to a lateral position
Correct answer: Administer naloxone (Narcan) as ordered
Naloxone rapidly reverses opioid-induced respiratory depression and is the priority intervention to restore adequate ventilation.
Question 3: A nurse assesses a client with left-sided heart failure. Which finding is most consistent with this diagnosis?
- Peripheral pitting edema
- Jugular vein distension
- Crackles in the lung bases (Correct answer)
- Hepatomegaly
Correct answer: Crackles in the lung bases
Left-sided heart failure causes pulmonary congestion, leading to fluid accumulation in the alveoli and crackles on auscultation.
Question 4: A nurse is preparing to administer a blood transfusion. After hanging the blood, the client develops chills, back pain, and dark urine within 15 minutes. What should the nurse do first?
- Slow the transfusion rate and monitor vital signs
- Stop the transfusion and keep the IV line open with normal saline (Correct answer)
- Administer diphenhydramine (Benadryl) IV as ordered
- Obtain a urine specimen and notify the lab
Correct answer: Stop the transfusion and keep the IV line open with normal saline
These signs indicate an acute hemolytic reaction; the transfusion must be stopped immediately and the IV kept patent with NS to prevent renal failure.
Question 5: A client with tuberculosis (TB) is placed on airborne precautions. Which PPE is required when entering the room?
- Surgical mask, gloves, and gown
- N95 respirator, gloves, and gown (Correct answer)
- N95 respirator only
- Surgical mask and eye protection
Correct answer: N95 respirator, gloves, and gown
An N95 or higher-level respirator is required for airborne precautions; gloves and gown are added for contact with the patient or environment.
Question 6: A nurse is teaching a client newly prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- I will have my INR checked regularly.
- I will use a soft toothbrush to prevent bleeding gums.
- I can take ibuprofen for my arthritis pain. (Correct answer)
- I will avoid large amounts of leafy green vegetables.
Correct answer: I can take ibuprofen for my arthritis pain.
NSAIDs like ibuprofen increase bleeding risk when combined with warfarin and should be avoided; acetaminophen is the safer analgesic choice.
Question 7: A nurse is assessing a 2-year-old child. Which finding requires further follow-up?
- Weight at the 50th percentile
- Anterior fontanel closed
- Builds a tower of only 4 blocks (Correct answer)
- Uses 2-word phrases
Correct answer: Builds a tower of only 4 blocks
A 2-year-old should stack at least 6 blocks; stacking only 4 blocks suggests a fine motor delay that warrants further evaluation.
RN NCLEX-RN 2
A nurse is caring for a client with chronic kidney disease (CKD) who has a potassium level of 6.2 mEq/L.
Which dietary instruction is most important?