NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
Correct Answer: B
Rationale: Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.
Question 2 of 5
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
Question 3 of 5
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
Question 4 of 5
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do?
Correct Answer: D
Rationale: A verbal explanation in age-appropriate terms helps a 9-year-old understand the procedure, reducing anxiety and promoting cooperation.
Question 5 of 5
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.