Questions 151

NCLEX-RN

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Question 1 of 5

A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse should assess the client for which of the following fears common in this age group?

Correct Answer: C

Rationale: School-age children (7 years) commonly fear injury and pain, especially in medical settings, due to their growing awareness of bodily harm.

Question 2 of 5

A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?

Correct Answer: C

Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Flumazenil is the antidote for benzodiazepine reversal. Phytonadione is the antidote for warfarin sodium. Naloxone hydrochloride reverses respiratory depression caused by an opioid.

Question 3 of 5

When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer: A,D,E,F

Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.

Question 4 of 5

When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?

Correct Answer: D

Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.

Question 5 of 5

You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?

Correct Answer: D

Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.

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