NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
Question 2 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.
Question 3 of 5
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which of the following side effects?
Correct Answer: B
Rationale: Metoprolol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.
Question 4 of 5
The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
Question 5 of 5
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.