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
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 3 of 5
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
Question 4 of 5
The nurse is instructing a Hindu client to increase protein in the diet. Which of the following foods are appropriate to include in this client's diet? Select all that apply.
Correct Answer: A
Rationale: Hindus typically follow a vegetarian diet, so lentil soup is appropriate, while meat-based options like hamburger, veal, and fish are not.
Question 5 of 5
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.