NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.
Question 2 of 5
When desmopressin acetate is prescribed via intranasal route for a child diagnosed with von Willebrand's disease, the nurse instructs the parents regarding the administration of this medication. Which statement by the parents indicates a need for further teaching?
Correct Answer: B
Rationale: Parents should be instructed to reduce fluid intake during initial treatment because the treatment will prevent continued fluid loss and the result will be fluid buildup. The medication should be refrigerated, but freezing should be avoided. Side effects of the medication include facial flushing, nasal congestion, increased blood pressure, nausea, abdominal cramps, decreased urination, and vulval pain. Signs and symptoms of water intoxication include headache, drowsiness and confusion, weight gain, seizures, and coma.
Question 3 of 5
The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
Question 4 of 5
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
Question 5 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.