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 heart failure who is receiving carvedilol (Coreg). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
Question 3 of 5
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.
Question 4 of 5
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.
Question 5 of 5
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.