Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

The nurse is evaluating the client's potential for development of a pressure sore. Which of the following individual characteristics would be the best indicator of risk for the client's developing a pressure sore?

Correct Answer: C

Rationale: Immobility is the primary risk factor for pressure sores, as it leads to prolonged pressure on tissues.

Question 2 of 5

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?

Correct Answer: D

Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.

Question 3 of 5

A client with a diagnosis of breast cancer is prescribed letrozole (Femara). The nurse should instruct the client to report which of the following side effects immediately?

Correct Answer: B

Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of letrozole requiring immediate reporting.

Question 4 of 5

A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?

Correct Answer: D

Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.

Question 5 of 5

A client with a history of bipolar disorder is prescribed carbamazepine (Tegretol). The nurse should monitor the client for which of the following side effects?

Correct Answer: B

Rationale: Carbamazepine can cause agranulocytosis, requiring regular monitoring of white blood cell counts.

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