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
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.
Question 3 of 5
The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
Correct Answer: A
Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.
Question 4 of 5
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
Question 5 of 5
A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client for:
Correct Answer: C
Rationale: Hoarseness is a common symptom of metastatic lung cancer due to tumor effects on the larynx or recurrent laryngeal nerve. Constipation, diarrhea, and weight gain are less specific.