NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 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 2 of 5
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
Question 3 of 5
A client has atrial fibrillation. The nurse should monitor the client for:
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
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
A client with a history of epilepsy is prescribed lamotrigine (Lamictal). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: A rash may indicate a serious hypersensitivity reaction to lamotrigine, such as Stevens-Johnson syndrome, requiring immediate reporting.