NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A postoperative nursing goal for the infant who has had surgery to correct imperforate anus is to prevent tension on the perineum. To achieve this goal, the nurse should not place the neonate on the:
Correct Answer: A
Rationale: The abdominal position with legs tucked increases perineal tension, risking surgical site strain, unlike the other positions.
Question 2 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 3 of 5
Methylphenidate is prescribed for a child with a diagnosis of attention deficit hyperactivity disorder (ADHD). At which time of day should the nurse instruct the mother to administer the medication?
Correct Answer: D
Rationale: Methylphenidate is a central nervous stimulant and should be taken before breakfast and before the noontime meal. It should not be taken in the afternoon or evening because the stimulating effect causes insomnia. The remaining options are incorrect.
Question 4 of 5
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
Question 5 of 5
The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
Correct Answer: B
Rationale: Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered.
Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.