NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.
Question 2 of 5
The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
Correct Answer: C
Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.
Question 3 of 5
The nurse is preparing to hang a unit of blood on a client. The blood has been checked off with two RNs and the pre-infusion vitals recorded. The nurse is at the bedside monitoring the infusion. Shortly after beginning the infusion, the pump alarm sounds. The IV has infiltrated. No blood has yet reached the client. The client is a hard stick, and the nurse realizes that a line cannot be placed within the time frame to begin the infusion. Which action by the nurse is correct?
Correct Answer: C
Rationale: Since no blood reached the client and IV access cannot be re-established within the time frame, the nurse should cancel the order and notify the provider to reassess the need for transfusion.
Question 4 of 5
An electrical fire occurs in a client's room shortly after the client returns from the recovery room after repair of a hip fracture with insertion of a prosthesis. What is the best method of removing the client from the room?
Correct Answer: C
Rationale: Moving the bed with the client on it (
C) is the safest and fastest method to evacuate a post-surgical client with limited mobility during an emergency like a fire. Other methods (A, B,
D) risk injury or delay.
Question 5 of 5
An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?
Correct Answer: B
Rationale: Reassigning the client to a different room (
B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (
A), medication (
C), or family presence (
D) may not fully alleviate the specific concern.