NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM COMPLETE 500 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

NCLEX RN ACTUAL EXAM 2023-2024 /RN

NCLEX ACTUAL EXAM 2023-2024 COMPLETE

500 QUESTIONS AND CORRECT DETAILED

ANSWERS WITH RATIONALES (VERIFIED

ANSWERS) |ALREADY GRADED A+

The nurse is caring for a client with diabetic ketoacidosis and documents that the

client is experiencing Kussmaul's respirations. Which patterns did the nurse

observe? Select all that apply.

A. Respirations that are shallow

B. Respirations that are increased in rate

C. Respirations that are abnormally slow

D. Respirations that are abnormally deep

E. Respirations that cease for several seconds - ANSWER- B, D

Rationale:

Kussmaul's respirations are abnormally deep and increased in rate. These occur as

a result of the compensatory action by the lungs. In bradypnea, respirations are

regular but abnormally slow. Apnea is described as respirations that cease for

several seconds.

The nurse is caring for a client with several broken ribs. The client is most likely to

experience what type of acid-base imbalance?

A. Respiratory acidosis from inadequate ventilation

B. Respiratory alkalosis from anxiety and hyperventilation

C. Metabolic acidosis from calcium loss due to broken bones

D. Metabolic alkalosis from taking analgesics containing base products -

ANSWER- A

Rationale:

Respiratory acidosis is most often caused by hypoventilation. The client with

broken ribs will have difficulty with breathing adequately and is at risk for

hypoventilation and resultant respiratory acidosis. The remaining options are

incorrect. Respiratory alkalosis is associated with hyperventilation. There are no

data in the question that indicate calcium loss or that the client is taking analgesics

containing base products.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin

sodium has a prothrombin time (PT) of 35 seconds. On the basis of these

laboratory values, the nurse anticipates which prescription?

A. Adding a dose of heparin sodium

B. Holding the next dose of warfarin

C. Increasing the next dose of warfarin

D. Administering the next dose of warfarin - ANSWER- B

Rationale:

The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A

therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the

value of 35 seconds is high, the nurse should anticipate that the client would not

receive further doses at this time. Therefore, the prescriptions noted in the

remaining options are incorrect.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned

to care for a client with chronic pain. Which statement, if made by the new

graduate nurse, indicates the need for further teaching regarding pain management?

A. "I will be sure to ask my client what his pain level is on a scale of 0 to 10."

B. "I know that I should follow up after giving medication to make sure it is

effective."

C. "I will be sure to cue in to any indicators that the client may be exaggerating

their pain."

D. "I know that pain in the older client might manifest as sleep disturbances or

depression." - ANSWER- C

Rationale:

Pain is a highly individual experience, and the new graduate nurse should not

assume that the client is exaggerating his pain. Rather, the nurse should frequently

assess the pain and intervene accordingly through the use of both

nonpharmacological and pharmacological interventions. The nurse should assess

pain using a number-based scale or a picture-based scale for clients who cannot

verbally describe their pain to rate the degree of pain. The nurse should follow up

with the client after giving medication to ensure that the medication is effective in

managing the pain. Pain experienced by the older client may be manifested

differently than pain experienced by clients in other age groups, and they may have

sleep disturbances, changes in gait and mobility, decreased socialization, and

depression; the nurse should be aware of this attribute in this population.

A client has been admitted to the hospital for gastroenteritis and dehydration. The

nurse determines that the client has received adequate volume replacement if the

blood urea nitrogen (BUN) level drops to which value?

A. 1.3 mg/dL (1.08 mmol/L)

B. 2.15 mg/dL (5.4 mmol/L)

C. 3.29 mg/dL (10.44 mmol/L)

D. 4.35 mg/dL (12.6 mmol/L) - ANSWER- B

Rationale:

The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL

(10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A

value of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may

occur with fluid volume overload, among other conditions.

A client is receiving a continuous intravenous infusion of heparin sodium to treat

deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is

65 seconds. The nurse anticipates that which action is needed?

A. Discontinuing the heparin infusion

B. Increasing the rate of the heparin infusion

C. Decreasing the rate of the heparin infusion

D. Leaving the rate of the heparin infusion as is - ANSWER- D

Rationale:

The normal aPTT varies between 30 and 40 seconds (30 and 40 seconds),

depending on the type of activator used in testing. The therapeutic dose of heparin

for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to 60)

and 2.5 (75 to 100) times normal. This means that the client's value should not be

less than 45 seconds or greater than 100 seconds. Thus, the client's aPTT is within

the therapeutic range and the dose should remain unchanged.

A client with a history of heart failure is due for a morning dose of furosemide.

Which serum potassium level, if noted in the client's laboratory report, should be

reported before administering the dose of furosemide?