NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A female client comes for her second prenatal visit. The nurse-midwife tells her, 'Your blood tests reveal that you do not show immunity to the German measles.' Which notation will the nurse include in her plan of care for the client? 'Will need . . .
Correct Answer: D
Rationale: Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. The rubella vaccine is not given during pregnancy because of its teratogenicity. Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
Question 2 of 5
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
Order the Items
Source Container
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.
Question 3 of 5
An appropriate nursing intervention for the client with borderline personality disorder is:
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
Question 4 of 5
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which intervention is most appropriate to prevent toxicity?
Correct Answer: D
Rationale: Magnesium sulfate toxicity can cause respiratory depression loss of reflexes and reduced urine output. Monitoring respiratory rate reflexes and urine output is essential to detect toxicity early and ensure patient safety.
Question 5 of 5
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
Correct Answer: A
Rationale: The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. The nurse should approach the parents in private, away from the child. Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's 'accident.' At this point, the parents may get defensive and stop communicating. Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.