NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
Question 2 of 5
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
Question 3 of 5
A postoperative client is prescribed incentive spirometry. What is the primary purpose of this intervention?
Correct Answer: A
Rationale: Incentive spirometry encourages deep breathing to expand alveoli, preventing atelectasis after surgery.
Question 4 of 5
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
Question 5 of 5
A client reports having pain in his casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. Which action is most appropriate for the nurse to take at this time?
Correct Answer: D
Rationale: Swelling and unrelieved pain in a casted arm suggest possible compartment syndrome, requiring immediate physician notification. Elevating the arm or applying ice may help but is secondary to reporting.