NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
Question 2 of 5
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
Question 3 of 5
The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
Question 4 of 5
At a 6-month-old infant is being admitted from the emergency department with dehydration secondary to viral gastroenteritis. Which of the following room assignments is the most appropriate for this infant?
Correct Answer: C
Rationale: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room to prevent the spread of infection.
Question 5 of 5
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.