NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?
Correct Answer: C
Rationale: Checking the suction equipment ensures the NG tube is functioning properly, addressing the most likely cause of distention before escalating to other interventions.
Question 2 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.
Question 3 of 5
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
Question 4 of 5
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
Correct Answer: D
Rationale: The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.
Question 5 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.