NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.
Correct Answer: B,D,E
Rationale: Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. The infant is kept nothing by mouth (NPO) so that the intravenous (IV) site and fluids are maintained. The infant should be placed in a side-lying position and the viscera supported with a blanket roll to prevent vascular compromise to a torqued intestine. Before surgery, the exposed viscera should be kept covered with sterile moistened saline gauze and plastic wrap. Thermoregulation is critical, so the infant should be placed in a warmer crib, not an open crib. The movement of the infant should be minimized, so parents are not allowed to hold the infant before surgery.
Question 2 of 5
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.
Question 3 of 5
The administration of an intramuscular injection to a neonate should be given in the:
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
Question 4 of 5
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
Question 5 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.