NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Question 1 of 5
Which client is at highest risk for developing a pressure ulcer?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
Correct Answer: B
Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.
Question 3 of 5
A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
Correct Answer: D
Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.
Question 4 of 5
The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Correct Answer: D
Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.
Question 5 of 5
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
Correct Answer: D
Rationale: During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.