NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A 12-year-old boy has a fractured femur and is immobilized in traction as shown in the fi gure. The nurse should:
Correct Answer: D
Rationale: The traction is set up correctly. Additional weights are not needed. A well-balanced diet with fiber should be offered. A pillow under the leg would negate the effects of the traction. Because the adolescent is positioned this way for an extended period, the nurse can help by fi nding activities that interest the client.
Question 2 of 5
The administration of an intramuscular injection to a neonate should be given in the:
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
Question 3 of 5
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TC
A). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.
Question 4 of 5
The nurse is teaching a client with diabetes mellitus about foot care. Which of the following instructions is most important?
Correct Answer: B
Rationale: Inspecting feet daily for cuts or sores is critical to prevent infections, a common complication in diabetes.
Question 5 of 5
The nurse has an order to administer ampicillin (Omnipen) 250 mg I.M. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
Correct Answer: A
Rationale:
To administer 250 mg from a 500 mg/mL solution, the calculation is 250 mg / 500 mg/mL = 0.5 mL.