NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
Correct Answer: A
Rationale: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
Question 2 of 5
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
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 notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console should the nurse check?
Correct Answer: D
Rationale: The amplitude, commonly called 'gain,' regulates the size of the complex and can be adjusted up and down to some degree. The power button turns the machine on and off. The low and high alarm settings indicate the heart rate limits beyond which an alarm will sound.
Question 5 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.