NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
Question 2 of 5
A client is admitted to the hospital with a tentative diagnosis of urinary tract infection (UTI). The nurse should assess the client for which of the following as a precipitating factor for the UTI?
Correct Answer: D
Rationale: Frequent sexual intercourse is a common precipitating factor for UTIs, as it can introduce bacteria into the urinary tract.
Question 3 of 5
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.
Question 4 of 5
A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
Question 5 of 5
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
Correct Answer: A,B,C,E,F,G
Rationale: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.