NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TC
A). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.
Question 2 of 5
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
Question 3 of 5
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
Correct Answer: C
Rationale: Hypokalemia can result from long-term use of casanthranol, which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal range for sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The remaining options all suggest normal values.
Question 4 of 5
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
Question 5 of 5
Intussusception occurs when:
Correct Answer: A
Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction, most commonly in children.