NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
Correct Answer: B
Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the client's formulation of a plan for the suicide attempt. Although all of the choices are correct, preventing self-harm is the priority in the context of the suicidal client. Clients with a history of self-harm are greater suicide risks.
Question 2 of 5
Select the age group that is accurately paired with the normal and recommended hours of sleep each day.
Correct Answer: B
Rationale:
Toddlers (1-2 years) typically require 11-14 hours of sleep per day, including naps, which is the correct pairing.
Question 3 of 5
An adolescent tells the school nurse she thinks she has infectious mononucleosis. The nurse should next assess the client for?
Correct Answer: A
Rationale: Sore throat and malaise are hallmark symptoms of mononucleosis, requiring targeted assessment.
Question 4 of 5
You are preparing to administer a PRN medication for pain. After your assessment of the client for pain you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client's room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client's refusal on the narcotics count record. What have you failed to do during this process?
Correct Answer: A
Rationale: Narcotic wastage (both 0.2 mL and 0.8 mL) requires a witness to ensure accountability and prevent diversion, per standard protocol.
Question 5 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.