NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.
Question 2 of 5
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (
B), monitoring for respiratory involvement with resuscitation equipment (
C), and ongoing assessment of paresthesia (
D). Family visits and ankle pumps are not priorities.
Question 3 of 5
A postmenopausal client with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which of the following statements by the nurse provides the client with accurate information?
Correct Answer: D
Rationale: Progesterone in hormone replacement therapy is used to prevent endometrial hyperplasia and cancer in women with an intact uterus. It does not primarily prevent cervical, breast, or liver disease.
Question 4 of 5
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
Question 5 of 5
The nurse is caring for a client with a history of peptic ulcer disease who is prescribed misoprostol (Cytotec). The nurse should instruct the client to take the medication:
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal side effects and protect the stomach lining.