NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client has atrial fibrillation. The nurse should monitor the client for:
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
Question 2 of 5
Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
Question 3 of 5
You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer's disease. You are planning a session on the stages of Alzheimer's disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session?
Correct Answer: B
Rationale: The Reisberg Scale (Global Deterioration Scale) indicates that in the first stage, individuals with Alzheimer's may cover up their failing abilities, which is an important point to include for caregivers to understand early disease behaviors.
Question 4 of 5
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.
Question 5 of 5
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.