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
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
Question 3 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 4 of 5
Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply.
Correct Answer: B,C,D,F
Rationale: The infant with congenital hypothyroidism may display the following signs: skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, bradycardia, and a distended abdomen. Other signs and symptoms include prolonged jaundice, lethargy, constipation, feeding problems, coldness to touch, umbilical hernia, hoarse cry, and excessive sleeping.
Question 5 of 5
A client with a history of liver failure is prescribed lactulose (Cephulac). The nurse should monitor the client for which of the following therapeutic effects?
Correct Answer: A
Rationale: Lactulose reduces ammonia levels by promoting its excretion in hepatic encephalopathy.