NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
Question 2 of 5
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
Question 3 of 5
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
Question 4 of 5
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
Question 5 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.