NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
Correct Answer: D,G,F,A
Rationale:
To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (
A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (
D).
Question 2 of 5
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
Question 3 of 5
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.
Question 4 of 5
Which statement about Respondeat Superior is accurate?
Correct Answer: A
Rationale: Respondeat Superior is a legal doctrine holding employers liable for employees' actions within the scope of employment, but it does not absolve nurses from personal liability for negligence.
Question 5 of 5
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
Order the Items
Source Container
Correct Answer: D,G,F,A
Rationale:
To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (
A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (
D).