NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (
B), monitoring for respiratory involvement with resuscitation equipment (
C), and ongoing assessment of paresthesia (
D). Family visits and ankle pumps are not priorities.
Question 2 of 5
The nurse is teaching unlicensed assistive personnel about caring for a client who is withdrawing from alcohol and street drugs. Which of the following communication techniques when observed by the nurse indicate the UAP has understood the instructions? The UAP talks to the client using:
Correct Answer: A
Rationale: A matter-of-fact manner with short sentences is effective for clients withdrawing from substances, as it minimizes confusion and agitation.
Question 3 of 5
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.
Question 4 of 5
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.
Question 5 of 5
Which statement about total parenteral nutrition is true?
Correct Answer: C
Rationale: The Valsalva maneuver is used when changing TPN tubing to prevent air embolism by increasing intrathoracic pressure.