NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which instruction should be given to the client who has been prescribed a dry powder inhaler for treatment of COPD?
Correct Answer: A, D, E
Rationale: Dry powder inhaler use involves removing the cap and shaking (
A), placing the mouthpiece in the mouth (
D), and weekly dry cleaning (E). Rinsing (
B) risks moisture damage, and spacers (
C) are typically for metered-dose inhalers.
Question 2 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 3 of 5
The nurse is caring for a client with a recent stroke. Which position is most appropriate for this client?
Correct Answer: C
Rationale: Side-lying with the head elevated 30 degrees reduces intracranial pressure and promotes venous drainage in stroke clients, minimizing complications like cerebral edema. Supine, prone, or sitting positions may increase pressure or risk aspiration.
Question 4 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 5 of 5
A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
Correct Answer: B
Rationale: Cisplatin is nephrotoxic, and adequate hydration helps dilute the drug and protect the kidneys, reducing the risk of renal damage.