NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.
Question 2 of 5
Which nursing assessment findings indicate normal vital signs in a newborn infant?
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute.
Therefore, the other options are incorrect.
Question 3 of 5
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
Question 4 of 5
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.
Question 5 of 5
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.