NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
Question 2 of 5
You routinely use the PQRST method to assess pain. The PQRST method consists of:
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
Question 3 of 5
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
Question 4 of 5
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.
Question 5 of 5
A client with a history of schizophrenia is prescribed ziprasidone (Geodon). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Ziprasidone can cause prolonged QT interval, increasing arrhythmia risk.