NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 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 2 of 5
The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?
Correct Answer: C
Rationale: NPH is an intermediate-acting insulin with a peak time in 4 to 12 hours. The remaining options describe periods of time that are either too short or too long.
Question 3 of 5
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
Question 4 of 5
The nurse is caring for a client taking memantine. Which data should the nurse monitor for this client?
Correct Answer: C
Rationale: Memantine is a medication used to treat moderate to severe Alzheimer's disease. This medication needs to be avoided in clients with severe renal dysfunction, and a reduced dosage is needed in moderate renal dysfunction. The other options are not specifically associated with this medication.
Question 5 of 5
A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?
Correct Answer: B
Rationale: The parents are instructed to report signs of skin breakdown or stomal complications, such as ribbonlike stools or failure to pass flatus or stools, to the primary health care provider or the nurse. Moist, red granulation tissue may grow around an ostomy site and does not require special treatment. The remaining options are incorrect actions and considered contraindicated.