NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?
Correct Answer: A
Rationale: Poor nutritional status impairs skin integrity and healing, making it the most critical factor for skin breakdown.
Question 2 of 5
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
Question 3 of 5
The nurse talks to students at a high school about sexually transmitted infections (STIs). Which effective methods of preventing STIs does the nurse include in the discussion? Select all that apply.
Correct Answer: D,E,F
Rationale: Effective measures to avoid STIs include abstinence, using condoms properly, and avoiding multiple partners, and the nurse should provide this factual information to the high school students. The nurse also includes information about ineffective methods of preventing STIs, including birth control pills, oral sex, and diaphragms.
Question 4 of 5
An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
Question 5 of 5
A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.