NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

NCLEX-RN

NCLEX-RN Test Bank

NCLEX-RN Exam Practice Questions

Extract:


Question 1 of 5

The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

Correct Answer: A

Rationale:
To elicit the biceps reflex the nurse places a thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer. The other methods describe techniques for eliciting different reflexes (e.g. triceps or patellar).

Question 2 of 5

A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

Correct Answer: C

Rationale: Tetramune protects against diphtheria, pertussis, tetanus, and H. influenzae b and is part of a series given at 2, 4, 6, and 15-18 months. It does not test susceptibility or cover MMRV.

Question 3 of 5

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

Correct Answer: A

Rationale: MRSA (methicillin-resistant Staphylococcus aureus) requires contact precautions and a private room to prevent transmission. Diabetes pancreatitis and Addison’s disease do not require isolation unless other infectious conditions are present.

Question 4 of 5

The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

Correct Answer: A

Rationale: Oxytocin is used to induce labor by stimulating uterine contractions in a term pregnancy.

Question 5 of 5

Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?

Correct Answer: D

Rationale: (A, B,
C) The individual's systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A-C choices, and client should receive more frequent evaluations and care.

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