NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
Question 2 of 5
A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?
Correct Answer: D
Rationale: Normal blood pressure readings are less than 120/80 mm Hg. A blood pressure reading between 120/80 mm Hg and 139/89 mm Hg is considered to be a prehypertensive state. From the readings provided in the options, the correct option identifies the most successful outcome, although the reading indicates a prehypertensive state.
Question 3 of 5
The nurse is working in a newborn nursery and caring for several neonates. Precautions that should be taken to prevent an infant abduction include which of the following?
Correct Answer: A,D
Rationale: Notifying security about suspicious individuals and responding to exit alarms are key to preventing abductions. Taking multiple neonates or placing them near doorways increases risk.
Question 4 of 5
A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). The nurse should instruct the client that it may take how long to notice the full therapeutic effect?
Correct Answer: C
Rationale: Fluoxetine, an SSRI, typically takes 3-4 weeks to achieve its full therapeutic effect in treating depression.
Question 5 of 5
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.