NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Correct Answer: B
Rationale: Offering a pacifier can disrupt the surgical repair of a cleft lip by placing pressure on the suture line. Holding, providing a mobile, and offering sterile water are safe and comforting.
Question 2 of 5
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 3 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.
Question 4 of 5
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Correct Answer: B
Rationale: Offering a pacifier can disrupt the surgical repair of a cleft lip by placing pressure on the suture line. Holding, providing a mobile, and offering sterile water are safe and comforting.
Question 5 of 5
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving Methotrexate (Rheumatrex). The nurse should monitor the client for:
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and thrombocytosis are not common side effects.