NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
Correct Answer: D
Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.
Question 2 of 5
A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
Correct Answer: D
Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing.
Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.
Question 3 of 5
A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
Correct Answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.
Question 4 of 5
A healthcare professional is reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
Correct Answer: A
Rationale: Lyme disease, the most common vector-borne disease in the United States, is caused by the bacterium Borrelia burgdorferi. Borrelia burgdorferi is transmitted to humans through the bite of infected black-legged ticks. Streptococcus pyogenes is associated with strep throat and other infections, not Lyme disease. Bacillus anthracis causes anthrax, a separate infectious disease. Enterococcus faecalis is more commonly linked to urinary tract infections and other healthcare-associated infections, not Lyme disease.
Question 5 of 5
A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
Correct Answer: B
Rationale: Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart is unable to circulate blood normally, the kidneys receive less blood, leading to reduced fluid filtration into the urine. The excess fluid accumulates in various body parts such as the lungs, liver, eyes, and sometimes in the legs. Slow pulse rate (
Choice
A) is less likely as infants with heart failure typically present with tachycardia due to the body compensating for decreased cardiac output. Decreased systolic pressure (
Choice
C) is also less likely as heart failure typically leads to increased blood pressure as the body tries to maintain adequate perfusion. Irregular white blood cell (WB
C) values (
Choice
D) are not directly associated with congenital heart defects unless there is an underlying infection or inflammatory process.