NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
Question 2 of 5
The nurse is teaching a client with diabetes mellitus about foot care. Which of the following instructions is most important?
Correct Answer: B
Rationale: Inspecting feet daily for cuts or sores is critical to prevent infections, a common complication in diabetes.
Question 3 of 5
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TC
A). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.
Question 4 of 5
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
Question 5 of 5
Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.