NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The most appropriate toys to give to a 5-month-old infant are:
Correct Answer: D
Rationale: Soft, washable toys are safe and appropriate for a 5-month-old, who explores through touch and mouthing.
Toy cars and puzzles are choking hazards, and stuffed animals may pose hygiene risks.
Question 2 of 5
The nurse is caring for a client with a history of peptic ulcer disease who is prescribed misoprostol (Cytotec). The nurse should instruct the client to take the medication:
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal side effects and protect the stomach lining.
Question 3 of 5
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.
Question 4 of 5
Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
Question 5 of 5
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.