NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
Which emergency interventions should be carried out for the patient with a venomous snake bite of the right hand?
Correct Answer: A, E
Rationale: Snake bite management includes lying down (
A) to reduce venom spread and immobilizing the limb below heart level (E) to slow circulation. Oral antihistamines (
B) are ineffective acutely, history (
C) is secondary, and anti-venin testing (
D) is controversial and not routine.
Question 2 of 5
The nurse is assessing the vital signs of a client with pancreatic cancer. In addition to routine vital signs, the nurse assesses the fifth vital sign of:
Correct Answer: B
Rationale: Pain is considered the fifth vital sign, alongside temperature, pulse, respiration, and blood pressure. It is routinely assessed, especially in conditions like pancreatic cancer, which often causes significant pain due to tumor invasion or obstruction.
Question 3 of 5
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
Correct Answer: A
Rationale: Oxytocin is used to induce labor by stimulating uterine contractions in a term pregnancy.
Question 4 of 5
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
Correct Answer: B
Rationale: Consistent limit setting will help the client to know what is acceptable behavior, addressing the disruptive actions effectively.
Question 5 of 5
An 8-week-old infant has been diagnosed with gastroesophageal reflux. The nurse is teaching the infant's mother to care for the infant at home. Which one of the following statements by the nurse is appropriate regarding the infant's home care?
Correct Answer: D
Rationale: Elevating the child's head to a 30-degree angle is the recommended position for gastroesophageal reflux. The supine position predisposes the child to aspiration. Small, frequent feedings with thickened formula are recommended to minimize vomiting. Antacids should be given at the same time as the feeding to improve their buffering action. The infant should be kept still after feedings to reduce the risk of vomiting and aspiration. Vigorous activities should be carried out before feedings.