Questions 151

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NCLEX RN Test Bank Questions PDF Questions

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Question 1 of 5

You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?

Correct Answer: A

Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.

Question 2 of 5

You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:

Correct Answer: C

Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.

Question 3 of 5

A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?

Correct Answer: A

Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.

Question 4 of 5

The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?

Correct Answer: A

Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.

Question 5 of 5

You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?

Correct Answer: A

Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.

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