NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 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 2 of 5
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
Question 3 of 5
A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.
Question 4 of 5
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
Question 5 of 5
What is the purpose of administering diphenhydramine before a blood transfusion?
Correct Answer: A
Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.