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
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
Question 3 of 5
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.
Question 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
Question 5 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.