NCLEX RN· Full Length · NCLEX RN Practice Tests
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
A med-surg nurse is floating to the post-op floor for a few days. The float nurse sees one of the regular post-op nurses taking medication from the med cart and ingesting several pills. The float nurse should immediately
Expert Explanatory Rationale
Correct Answer: inform the nursing supervisor who works on the post-op floor.
Reporting to the nursing supervisor ensures prompt investigation and intervention for suspected medication diversion, maintaining patient safety.
To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
Expert Explanatory Rationale
Correct Answer: Dried beans, sweet potatoes, Brussels sprouts
Folic acid is found in foods like dried beans, sweet potatoes, and Brussels sprouts. These help reduce the risk of neural tube defects like spina bifida when consumed before and during early pregnancy.
A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
Expert Explanatory Rationale
Correct Answer: Wash the skin with water and pat dry
Washing the skin with water and patting dry ensures cleanliness and prevents irritation during hyperbaric oxygen therapy.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
Expert Explanatory Rationale
Correct Answer: notify the health care provider
Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
Expert Explanatory Rationale
Correct Answer: Vaginal bleeding.
vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
Expert Explanatory Rationale
Correct Answer: Meat, eggs, dairy products
Vitamin B12 is found in animal products like meat, eggs, and dairy, essential for treating pernicious anemia due to impaired B12 absorption.
The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
Expert Explanatory Rationale
Correct Answer: penicillin allergy.
Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
Expert Explanatory Rationale
Correct Answer: Encouraging fluid intake of at least 200 mL per hour
Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.
The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture uses:
Expert Explanatory Rationale
Correct Answer: Needles to stimulate certain points on the body to treat pain
Acupuncture uses needles, which pose an infection risk in immunocompromised AIDS patients, requiring further discussion.
A 34-year-old client is receiving an IM injection of ceftriaxone (Rocephin) for a urinary tract infection. Which is correct regarding IM injections?
Expert Explanatory Rationale
Correct Answer: The injection should be given at a 90-degree angle.
IM injections are given at a 90-degree angle to ensure muscle penetration. A 25-gauge needle is too small, a 45-degree angle is for subcutaneous injections, and a bleb indicates intradermal injection.