NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
Question 2 of 5
A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record. What should the nurse do first?
Correct Answer: D
Rationale: A distended bladder causing pain requires immediate relief via catheterization to prevent complications like urinary retention or bladder injury.
Question 3 of 5
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
Question 4 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 5 of 5
An adolescent with type 1 diabetes mellitus is hospitalized for appendicitis. He is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin. The nurse should suspect:
Correct Answer: A
Rationale: Fruity breath, weakness, nausea, and poor skin turgor in a type 1 diabetic suggest diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. Hypoglycemia would present with shakiness or sweating, not fruity breath.