NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure?
Correct Answer: D
Rationale: Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client's airway should be suctioned before cleansing the tracheostomy. New sterile solutions are obtained once per 24 hours, which is often done at the beginning of the workday. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and holder (trach ties).
Question 2 of 5
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
Question 3 of 5
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
Question 4 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.
Question 5 of 5
Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.
Correct Answer: B,C,E,G
Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.