NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
In the early postoperative period, the nurse notes a bright red, 3' x 5' area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
Correct Answer: C
Rationale: Bright red drainage suggests active bleeding, so taking vital signs to assess for hemodynamic instability is the priority.
Question 2 of 5
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
Question 3 of 5
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
Correct Answer: A,B,C,E,F,G
Rationale: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.
Question 4 of 5
The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
Question 5 of 5
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.