NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
Correct Answer: C
Rationale: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.
Question 2 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 3 of 5
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
Question 4 of 5
The nurse reviews the client's laboratory report to determine the client's blood level of valproic acid (Depakene), which is 35 mcg/mL. Based on this report, what should the nurse do first?
Correct Answer: B
Rationale: A valproic acid level of 35 mcg/mL is below the therapeutic range (50-100 mcg/mL), indicating a need to notify the physician for potential dose adjustment.
Question 5 of 5
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.