RN NCLEX-RN 5 — Questions and Answers
Question 1: A nurse is teaching a client with type 2 diabetes about sick-day management. Which instruction is most important?
- Stop taking insulin or oral medications when unable to eat.
- Continue taking diabetes medications and monitor blood glucose more frequently. (Correct answer)
- Restrict all fluid intake to prevent hypoglycemia.
- Contact the provider only if vomiting persists for more than 48 hours.
Correct answer: Continue taking diabetes medications and monitor blood glucose more frequently.
Illness increases stress hormones that raise blood glucose, so medications should be continued and glucose monitored more frequently during sick days.
Question 2: A nurse is caring for a laboring client who receives an epidural. Fifteen minutes later, the client's blood pressure drops from 118/76 to 82/50 mmHg. What is the priority intervention?
- Elevate the client's head to 90 degrees
- Administer oxygen at 10 L/min via face mask
- Turn the client to a lateral position and increase IV fluid rate (Correct answer)
- Notify the anesthesiologist before taking any action
Correct answer: Turn the client to a lateral position and increase IV fluid rate
Epidural-induced hypotension is treated by positioning the client laterally to relieve aortocaval compression and increasing IV fluids to restore preload.
Question 3: A nurse is assessing a client's wound and notes the edges are approximated with moderate serous drainage and no odor. Which wound classification applies?
- Infected wound healing by secondary intention
- Clean wound healing by primary intention (Correct answer)
- Contaminated wound requiring debridement
- Chronic wound with impaired healing
Correct answer: Clean wound healing by primary intention
Approximated wound edges with serous drainage and no signs of infection describe a clean wound healing by primary intention following surgical closure.
Question 4: A nurse is preparing to administer 0.5 mL of a medication subcutaneously. Which needle size and angle is correct?
- 18-gauge, 1.5-inch needle at 90 degrees
- 25-gauge, 5/8-inch needle at 45–90 degrees (Correct answer)
- 21-gauge, 1-inch needle at 15 degrees
- 23-gauge, 1.5-inch needle at 45 degrees
Correct answer: 25-gauge, 5/8-inch needle at 45–90 degrees
Subcutaneous injections use a 25–27-gauge, 5/8-inch needle inserted at 45–90 degrees depending on body mass to deposit medication into subcutaneous tissue.
Question 5: A nurse is receiving a verbal order from a physician via telephone. Which action reflects safe communication practice?
- Read the order back to the physician immediately after writing it down
- Ask another nurse to listen and witness the telephone order
- Document the order and have the physician sign it within 72 hours
- Repeat the order aloud while writing and ask the physician to confirm (Correct answer)
Correct answer: Repeat the order aloud while writing and ask the physician to confirm
Read-back and verbal confirmation of telephone orders is the Joint Commission-recommended practice to prevent transcription errors.
Question 6: A nurse is caring for a client with acute pancreatitis. Which position provides the most comfort?
- Supine with legs extended
- Semi-Fowler's with knees extended
- Fetal position with knees drawn to chest (Correct answer)
- Trendelenburg position
Correct answer: Fetal position with knees drawn to chest
The fetal (knee-chest) position reduces tension on the inflamed pancreas and surrounding abdominal structures, alleviating pain.
Question 7: A client is admitted with suspected meningitis. Which assessment finding is most suggestive of bacterial meningitis?
- Gradual onset of mild headache and low-grade fever
- Positive Kernig's sign and nuchal rigidity (Correct answer)
- Productive cough with purulent sputum
- Generalized pruritic rash without fever
Correct answer: Positive Kernig's sign and nuchal rigidity
Positive Kernig's sign (inability to extend the knee when the hip is flexed) and nuchal rigidity are classic meningeal irritation signs associated with bacterial meningitis.
RN NCLEX-RN 5
A nurse is teaching a client with type 2 diabetes about sick-day management.
Which instruction is most important?