NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client with a burn injury is prescribed silver sulfadiazine. What should the nurse monitor for?
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia, so monitoring white blood cell counts is essential.
Question 2 of 5
When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure?
Correct Answer: A
Rationale: Pre-oxygenation prevents hypoxia during tracheostomy suctioning, ensuring client safety.
Question 3 of 5
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
Question 4 of 5
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
Question 5 of 5
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.