NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as which of the following?
Correct Answer: B
Rationale: An indentation with a tuft of hair suggests spina bifida occulta, a mild defect without protrusion of spinal contents.
Question 2 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
Question 3 of 5
The nurse instructs the client in mixing and administering regular and NPH insulin. Which of the following statements indicates that the client needs additional instruction?
Correct Answer: B
Rationale: Shaking NPH insulin can damage it; it should be gently rolled. Drawing up regular insulin first, cool storage, and a 90-degree injection angle are correct practices.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
Question 5 of 5
The administration of an intramuscular injection to a neonate should be given in the:
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.