NCLEX-RN
NCLEX RN Test Bank with Rationales 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: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
Question 2 of 5
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should instruct the client to take the medication:
Correct Answer: B
Rationale: Ranitidine, an H2 receptor blocker, is most effective when taken at bedtime to reduce nighttime acid production and promote ulcer healing.
Question 3 of 5
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.
Question 4 of 5
A pregnant woman at 22 weeks' gestation is diagnosed with gonorrhea. The physician orders doxycycline (Vibramycin). The nurse should first:
Correct Answer: D
Rationale: Doxycycline is contraindicated in pregnancy due to risks to the fetus. The nurse should discuss changing the order to a safer alternative, such as ceftriaxone, which is recommended for gonorrhea in pregnancy.
Question 5 of 5
The nurse notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console should the nurse check?
Correct Answer: D
Rationale: The amplitude, commonly called 'gain,' regulates the size of the complex and can be adjusted up and down to some degree. The power button turns the machine on and off. The low and high alarm settings indicate the heart rate limits beyond which an alarm will sound.