NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
Question 2 of 5
When desmopressin acetate is prescribed via intranasal route for a child diagnosed with von Willebrand's disease, the nurse instructs the parents regarding the administration of this medication. Which statement by the parents indicates a need for further teaching?
Correct Answer: B
Rationale: Parents should be instructed to reduce fluid intake during initial treatment because the treatment will prevent continued fluid loss and the result will be fluid buildup. The medication should be refrigerated, but freezing should be avoided. Side effects of the medication include facial flushing, nasal congestion, increased blood pressure, nausea, abdominal cramps, decreased urination, and vulval pain. Signs and symptoms of water intoxication include headache, drowsiness and confusion, weight gain, seizures, and coma.
Question 3 of 5
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
Correct Answer: C
Rationale: Filing an incident report addresses the improper disposal of a medication, ensuring investigation and prevention of future errors.
Question 4 of 5
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
Correct Answer: D
Rationale: The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.
Question 5 of 5
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.