NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
Question 2 of 5
The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
Question 3 of 5
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.
Question 4 of 5
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
Question 5 of 5
How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL
Correct Answer: A
Rationale:
To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.