NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse should question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm?
Correct Answer: B
Rationale: The nurse should question a prescription for heparin sodium, which is an anticoagulant. This medication could place the client at risk for rebleeding. Nicardipine is a calcium channel-blocking agent that is useful in the management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It may be prescribed after ruptured intracranial aneurysm and subarachnoid hemorrhage if surgery is delayed or contraindicated.
Question 2 of 5
A client is admitted with acute glomerulonephritis. The nurse should monitor the client for which of the following?
Correct Answer: A, D
Rationale: Acute glomerulonephritis can cause hypertension (due to fluid retention) and hypoalbuminemia (due to proteinuria).
Question 3 of 5
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
Question 4 of 5
Which statement about total parenteral nutrition is true?
Correct Answer: C
Rationale: The Valsalva maneuver is used when changing TPN tubing to prevent air embolism by increasing intrathoracic pressure.
Question 5 of 5
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.