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
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.
Question 3 of 5
A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the client for which of the following side effects?
Correct Answer: A,D
Rationale: Risperidone can cause weight gain and extrapyramidal symptoms like tremors, which the nurse should monitor.
Question 4 of 5
A client with a history of rheumatoid arthritis is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
Correct Answer: A, B, C, D, E
Rationale: Prednisone can cause hyperglycemia, osteoporosis, weight gain, hypertension, and hypokalemia.
Question 5 of 5
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.