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
The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?
Correct Answer: C
Rationale: Tapering TPN prevents rebound hypoglycemia by allowing the body to adjust to reduced glucose infusion.
Question 3 of 5
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.
Question 4 of 5
The nurse notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console should the nurse check?
Correct Answer: D
Rationale: The amplitude, commonly called 'gain,' regulates the size of the complex and can be adjusted up and down to some degree. The power button turns the machine on and off. The low and high alarm settings indicate the heart rate limits beyond which an alarm will sound.
Question 5 of 5
The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.
Correct Answer: B,D,E
Rationale: Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. The infant is kept nothing by mouth (NPO) so that the intravenous (IV) site and fluids are maintained. The infant should be placed in a side-lying position and the viscera supported with a blanket roll to prevent vascular compromise to a torqued intestine. Before surgery, the exposed viscera should be kept covered with sterile moistened saline gauze and plastic wrap. Thermoregulation is critical, so the infant should be placed in a warmer crib, not an open crib. The movement of the infant should be minimized, so parents are not allowed to hold the infant before surgery.