NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.
Correct Answer: B,C,E,G
Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.
Question 2 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 3 of 5
An adolescent tells the school nurse she thinks she has infectious mononucleosis. The nurse should next assess the client for?
Correct Answer: A
Rationale: Sore throat and malaise are hallmark symptoms of mononucleosis, requiring targeted assessment.
Question 4 of 5
A 4-year-old child is admitted with a tentative diagnosis of Kawasaki disease. Which of the following laboratory findings is most likely to be found in this child?
Correct Answer: A
Rationale: Kawasaki disease is commonly associated with leukocytosis, reflecting the inflammatory process characteristic of the condition.
Question 5 of 5
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence