NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Question 1 of 5
When desmopressin acetate is prescribed via intranasal route for a child diagnosed with von Willebrand's disease, the nurse instructs the parents regarding the administration of this medication. Which statement by the parents indicates a need for further teaching?
Correct Answer: B
Rationale: Parents should be instructed to reduce fluid intake during initial treatment because the treatment will prevent continued fluid loss and the result will be fluid buildup. The medication should be refrigerated, but freezing should be avoided. Side effects of the medication include facial flushing, nasal congestion, increased blood pressure, nausea, abdominal cramps, decreased urination, and vulval pain. Signs and symptoms of water intoxication include headache, drowsiness and confusion, weight gain, seizures, and coma.
Question 2 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 3 of 5
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.
Question 4 of 5
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
Question 5 of 5
Intussusception occurs when:
Correct Answer: A
Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction, most commonly in children.