NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
Question 2 of 5
Select the basic sterile asepsis procedures that are accurate. Select all that apply:
Correct Answer: A,C,E
Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).
Question 3 of 5
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
Question 4 of 5
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
Question 5 of 5
A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.