NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 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 2 of 5
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which of the following?
Correct Answer: C
Rationale: Sterile gloves are unnecessary for bathing a neonate; clean gloves suffice, indicating a need for further instruction on standard precautions.
Question 3 of 5
The nurse instructs the client in mixing and administering regular and NPH insulin. Which of the following statements indicates that the client needs additional instruction?
Correct Answer: B
Rationale: Shaking NPH insulin can damage it; it should be gently rolled. Drawing up regular insulin first, cool storage, and a 90-degree injection angle are correct practices.
Question 4 of 5
Which statement about referrals is accurate?
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
Question 5 of 5
The nurse is teaching a client with a new colostomy about dietary management. 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, eggs, or beans, which may increase gas.