NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Excessive alcohol use, gallstones, abdominal trauma, and hyperlipidemia with high triglycerides are established risk factors for pancreatitis, as they can disrupt塌 or obstruct pancreatic ducts or cause inflammation.
Question 2 of 5
The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
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 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 5 of 5
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.