NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.
Question 2 of 5
The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
Question 3 of 5
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.
Question 4 of 5
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.
Question 5 of 5
Which of the following is a risk factor for toxic shock syndrome (TSS)?
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.