NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
Question 2 of 5
A client receiving chemotherapy has a platelet count of 15,000 mm³ (15 x 10â¹/L). Based on this laboratory result, which form of precautions should the nurse implement?
Correct Answer: B
Rationale: When the platelet count is less than 20,000 mm³ (20 x 10â¹/L), the client is at risk for bleeding, and the nurse should institute bleeding precautions. Contact precautions are initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. Neutropenic precautions would be instituted for a client with a low neutrophil count.
Question 3 of 5
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
Question 4 of 5
A client with a history of stroke is at risk for aspiration. Which of the following interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Upright positioning, assessing gag reflex, small frequent meals, and thickened liquids reduce aspiration risk. Thin liquids increase risk.
Question 5 of 5
A client with a history of heart failure is prescribed enalapril (Vasotec). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A, B
Rationale: Enalapril, an ACE inhibitor, can cause hyperkalemia and hypotension.