NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
Correct Answer: A
Rationale: A supportive environment fosters trust and safety in PTSD, aiding recovery. Discussing the attack or controlling emotions may retraumatize, and hypnotics are secondary.
Question 2 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 3 of 5
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:
Correct Answer: C
Rationale: Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus, leading to intrauterine growth retardation. Alcohol consumption also decreases birth weight.
Question 4 of 5
The nurse is preparing to administer a dose of vancomycin (Vancocin) IV. Which assessment is most important before administration?
Correct Answer: B
Rationale: Vancomycin is nephrotoxic, so renal function tests (e.g., creatinine) are critical before administration to prevent kidney damage. Liver tests, WBC, and platelets are less directly related.
Question 5 of 5
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
Correct Answer: A
Rationale: A supportive environment fosters trust and safety in PTSD, aiding recovery. Discussing the attack or controlling emotions may retraumatize, and hypnotics are secondary.