NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
Which tool or scale would you use for a focused neurological assessment of your client?
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.
Question 2 of 5
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
Question 3 of 5
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
Question 4 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 5 of 5
A client with a history of peptic ulcer disease is prescribed lansoprazole (Prevacid). The nurse should instruct the client to:
Correct Answer: A
Rationale: Lansoprazole is most effective when taken before meals to reduce acid production.