NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 2 of 5
Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?
Correct Answer: B
Rationale: Meningitis at six months can cause brain injury, contributing to cerebral palsy, a condition often linked to perinatal or early postnatal neurological damage. Full-term birth, physiologic jaundice, and sore throats are not directly related.
Question 3 of 5
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
Correct Answer: C
Rationale: Older clients have less effective immune systems, increasing their risk for influenza complications, making yearly vaccination critical.
Question 4 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 5 of 5
The physician has ordered a homocysteine blood level on a client.
Correct Answer: A
Rationale: Homocysteine levels rise with vitamin B12 deficiency, as B12 is needed for its metabolism. Deficiencies in vitamins C (
B), A (
C), and E (
D) do not significantly affect homocysteine.