NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of venous insufficiency who is prescribed horse chestnut extract. The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Horse chestnut extract may increase bleeding risk, so bleeding should be reported immediately.
Question 2 of 5
When giving a change of shift report, which of the following statements by the nurse is not appropriate?
Correct Answer: C
Rationale: Subjective statements like 'contrary' are inappropriate in a professional report, as they lack objectivity and clinical relevance.
Question 3 of 5
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.
Question 4 of 5
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
Question 5 of 5
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.