NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client?
Correct Answer: D
Rationale:
Total bilirubin of 17 umol/L (1 mg/dL) is elevated (normal 0.1-1.0 mg/dL), indicating potential liver or biliary issues, requiring reporting.
Question 2 of 5
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.
Question 3 of 5
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
Question 4 of 5
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.
Question 5 of 5
A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the neck. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.