NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals is most appropriate for the nurse to emphasize?
Correct Answer: D
Rationale: Regular blood pressure monitoring empowers clients to track their hypertension and adjust lifestyle or medication as needed.
Question 2 of 5
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
Question 3 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 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
Question 5 of 5
The nurse instructs a female client about collecting a midstream urine sample for culture and sensitivity. Which should the nurse include in client teaching?
Correct Answer: B
Rationale:
To prepare properly for collection of a sterile urine specimen, the client cleanses the perineum from front to back using antiseptic swabs. Bathing before a midstream urine collection is unnecessary; however, proper specimen handling is critically important because improper specimen handling can yield inaccurate test results. The specimen should be labeled with the client's name, date, time, and medical record number in addition to the provider's name. The client should begin the flow of urine and collect the sample after starting the flow of urine, and then send the specimen to the laboratory as soon as possible.