NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
Correct Answer: B
Rationale: Emptying the appliance when one-third full prevents urine stasis, reducing infection risk.
Question 2 of 5
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
Question 3 of 5
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.
Question 4 of 5
Which of the following is not considered one of the 'Ten Rights of Medication Administration'?
Correct Answer: A
Rationale: The Ten Rights of Medication Administration include right patient, drug, dose, route, time, documentation, reason, response, refusal, and education. 'Right verification' is not a standard right.
Question 5 of 5
The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.