NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
Correct Answer: A,D
Rationale: Spinal cord injury often causes anesthesia (loss of sensation) and loss of position/vibratory sense below the injury level. Tingling or pain below the injury is less likely due to disrupted nerve pathways.
Question 2 of 5
What is the purpose of administering diphenhydramine before a blood transfusion?
Correct Answer: A
Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.
Question 3 of 5
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
Question 4 of 5
An elderly client has been bedridden since a cerebrovascular accident that resulted in total right-sided paralysis. The client has become increasingly confused, is occasionally incontinent of urine, and is refusing to eat. In planning the client's care, which of the following factors should the nurse consider as most critical in contributing to skin breakdown in this client?
Correct Answer: A
Rationale: Poor nutritional status impairs skin integrity and healing, making it the most critical factor for skin breakdown.
Question 5 of 5
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.