NCLEX RN ACTUAL EXAM 2023-2024 RN

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.

• Respirations that are shallow
• Respirations that are increased in rate
• Respirations that are abnormally slow
• Respirations that are abnormally deep
• 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?

• Respiratory acidosis from inadequate ventilation 1 / 4

• Respiratory alkalosis from anxiety and hyperventilation
• Metabolic acidosis from calcium loss due to broken bones
• 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?

• Adding a dose of heparin sodium
• Holding the next dose of warfarin
• Increasing the next dose of warfarin
• 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.

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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?

• "I will be sure to ask my client what his pain level is on a scale of 0 to 10."
• "I know that I should follow up after giving medication to make sure it is

effective."

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

their pain."

• "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?

• 1.3 mg/dL (1.08 mmol/L)
• 2.15 mg/dL (5.4 mmol/L) 3 / 4

• 3.29 mg/dL (10.44 mmol/L)
• 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?

• Discontinuing the heparin infusion
• Increasing the rate of the heparin infusion
• Decreasing the rate of the heparin infusion
• 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?

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