NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.
Question 2 of 5
What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016?
Correct Answer: A
Rationale: Using Naegele's rule, add 1 year and 7 days to the first day of the last menstrual period (10/20/2016), then subtract 3 months: 10/20/2016 + 1 year = 10/20/2017, + 7 days = 10/27/2017, - 3 months = 7/27/2017. Adjusting for a standard 40-week gestation, the expected delivery date is approximately 7/7/2017.
Question 3 of 5
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.
Question 4 of 5
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.
Question 5 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.