NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?
Correct Answer: A
Rationale: Moving the client closer to the nursing station allows close monitoring without violating the client’s refusal of restraints, prioritizing safety and autonomy.
Question 2 of 5
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
Correct Answer: B
Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.
Question 3 of 5
A nurse receives an order to dilute ceftriaxone sodium powder in a vial prior to administration. The nurse should ensure the powder is fully diluted by
Correct Answer: B
Rationale: Rolling the vial between the palms gently mixes the powder with the diluent, ensuring full dilution without creating air bubbles or denaturing the medication.
Question 4 of 5
A client is receiving gentamicin sulfate (Gentamicin) injections as part of her treatment regimen for a pseudomonas infection. The nurse knows to assess for what potential adverse reaction to this medication?
Correct Answer: D
Rationale: Gentamicin, an aminoglycoside, is associated with ototoxicity (hearing loss or balance issues) as a major adverse effect, requiring close monitoring.
Question 5 of 5
A newborn diagnosed with bilateral choanal atresia is scheduled for surgery soon after delivery. The nurse recognizes the immediate need for surgery because the newborn:
Correct Answer: D
Rationale: Bilateral choanal atresia blocks the nasal passages, preventing nasal breathing, which is critical for newborns who are obligate nose breathers.