NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
Question 2 of 5
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
Question 3 of 5
The nurse has given client directions for the proper use of aluminum hydroxide tablets. The client indicates an understanding of the medication when which statement is made?
Correct Answer: D
Rationale: Aluminum hydroxide tablets should be chewed thoroughly before swallowing. This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 2 hours apart from other medications to prevent interactive effects. Constipation is a side effect of aluminum products, but the client should not take a laxative with each dose. This promotes laxative abuse. The client should first try other means to prevent constipation.
Question 4 of 5
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
Question 5 of 5
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.