NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A child with a known peanut allergy is eating lunch at summer camp and develops an anaphylactic reaction from accidentally ingesting peanut butter-flavored cookies. The nurse's first intervention should be to
Correct Answer: C
Rationale: In an anaphylactic reaction, the priority is to stop further allergen exposure. Verifying the child has stopped eating and has no cookies in their mouth prevents additional allergen ingestion, which is critical before administering epinephrine or other interventions.
Question 2 of 5
The client who is 2 weeks post-burn with a 40% deep partial-thickness injury still has open wounds. The nurse's assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea stools. What problem does the nurse most likely suspect?
Correct Answer: C
Rationale: Hypothermia, hypotension, and diarrhea suggest systemic gram-negative infection, likely sepsis, due to bacterial translocation from open wounds or the gut in a burn patient.
Question 3 of 5
The nurse is caring for a client with staphylococcus epidermidis. The client is on a vancomycin IV. What nursing consideration should the nurse be aware of regarding this medication?
Correct Answer: C
Rationale: Vancomycin requires monitoring trough levels (drawn before a dose) to ensure therapeutic efficacy and prevent toxicity.
Question 4 of 5
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
Correct Answer: B
Rationale: Pancreatitis can cause nausea and vomiting, and a Levine tube (nasogastric tube) is often used to decompress the stomach and prevent aspiration, which is a priority in the ICU setting.
Question 5 of 5
A client has been prescribed tetracycline (Sumycin) for Lyme disease. All of the following statements indicate successful client teaching regarding this medication EXCEPT
Correct Answer: A
Rationale: Tetracycline should not be taken with antacids, as they reduce absorption. The other statements are correct: pregnancy is a contraindication, photosensitivity requires sunscreen, and dairy products interfere with absorption.