NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?
Correct Answer: A
Rationale: Low back pain is a hallmark of acute hemolytic transfusion reaction due to hemolysis and kidney involvement. Fever, urticaria, or neck vein distention suggest other complications.
Question 2 of 5
The nurse is performing discharge instruction for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan?
Correct Answer: C
Rationale: Clients with pacemakers must monitor their pulse to ensure the device is functioning correctly and to detect irregularities, making pulse-taking an essential discharge instruction.
Question 3 of 5
The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:
Correct Answer: C
Rationale: Rest periods help manage fatigue and muscle weakness, common in post-polio syndrome.
Question 4 of 5
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
Correct Answer: A
Rationale: The biceps reflex is elicited by placing the thumb on the biceps tendon in the antecubital space and tapping it with a reflex hammer.
Question 5 of 5
A young male client who has recently become a quadriplegic makes a sexually inappropriate comment to the nurse. Which of the following statements by the nurse would be most appropriate?
Correct Answer: A
Rationale: Addressing the inappropriate comment directly sets clear boundaries while maintaining professionalism.