NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 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.
Question 2 of 5
A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
Question 3 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 4 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.
Question 5 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.