NCLEX RN· Full Length · NCLEX RN Practice Questions with Answers
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
Expert Explanatory Rationale
Correct Answer: It is not an emergency, but it is best to call the health care clinic.
The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?
Expert Explanatory Rationale
Correct Answer: Notify your health care provider because you may need medication.
Based on the signs and symptoms presented by the client (particularly the elevated temperature), the primary health care provider needs to be notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down.
The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
Expert Explanatory Rationale
Correct Answer: When the last alcoholic drink was consumed
Disulfiram may be used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. Therefore, it is important for the nurse to determine when the last alcoholic drink was consumed.
The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
Expert Explanatory Rationale
Correct Answer: Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia.
Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
The nurse is caring for a client with a history of glaucoma who is prescribed timolol (Timoptic) eye drops. The nurse should instruct the client to report which of the following side effects?
Expert Explanatory Rationale
Correct Answer: Bradycardia.
Timolol, a beta-blocker, can cause systemic effects like bradycardia, which should be reported immediately.
A mother is concerned about the amount of snacking her teenage boy is doing. She is concerned that this behavior could lead to obesity. Which of the following is an appropriate percentage of the daily diet to be obtained from snacks?
Expert Explanatory Rationale
Correct Answer: 25%.
Snacks should contribute about 25% of daily caloric intake to balance nutrition without leading to excessive weight gain.
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
Expert Explanatory Rationale
Correct Answer: 10 to 20 mL
The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should instruct the client to:
Expert Explanatory Rationale
Correct Answer: Take the medication with meals.
Sevelamer should be taken with meals to bind phosphate in the gut.
You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients?
Expert Explanatory Rationale
Correct Answer: The client will accept impending death
Accepting impending death is a common and appropriate goal for hospice clients, as it aligns with the focus of palliative care on achieving peace and closure at the end of life.
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
Expert Explanatory Rationale
Correct Answer: Apply the oxygen to the client.
The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation.
Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
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