NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
Correct Answer: C
Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.
Question 2 of 5
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
Question 3 of 5
A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?
Correct Answer: B
Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.
Question 4 of 5
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.
Question 5 of 5
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.