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
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
Correct Answer: C
Rationale: Filing an incident report addresses the improper disposal of a medication, ensuring investigation and prevention of future errors.
Question 3 of 5
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
Question 4 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 5 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.