NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
A patient is deciding whether they should take the live influenza vaccine (nasal spray) or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?
Correct Answer: D
Rationale: The correct answer is that the patient has young children. Having young children is not a contraindication for the live influenza vaccine unless the children are immunocompromised, which is not mentioned.
Choice A, the patient taking long-term corticosteroids, is a contraindication for the live vaccine due to potential immunosuppression.
Choice B, the patient not feeling well today, is a general precaution for vaccination and not a contraindication specific to the live influenza vaccine.
Choice C, the patient being 55 years old, is not a contraindication for the live vaccine unless there are other specific medical conditions present.
Question 2 of 5
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
Correct Answer: A
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (
Choice
B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (
Choice
C) or elevating the patient's leg (
Choice
D) may be necessary but do not address the immediate need for infection control measures.
Question 3 of 5
After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?
Correct Answer: B
Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.
Question 4 of 5
A patient has been taking mood stabilizing medication but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?
Correct Answer: D
Rationale: The correct answer is Risperidone (Risperdal) because it is the only medication among the options that does not require regular lab testing. Risperidone is not associated with the need for routine blood draws to monitor medication levels or potential side effects.
Choices A, B, and C (Valproic Acid, Clozapine, Lithium) are all known to require frequent lab monitoring due to various reasons such as potential toxicity, therapeutic drug levels, or adverse effects on certain organ functions.
Therefore, considering the patient's fear of needles and the desire to avoid frequent blood tests, Risperidone would be the most suitable option.
Question 5 of 5
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
Correct Answer: A
Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats.
Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.