NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
Correct Answer: A
Rationale: Nuchal rigidity is a critical sign of meningitis, indicating meningeal irritation and requiring immediate medical intervention to prevent complications.
Question 3 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 4 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 5 of 5
Which of the following would demonstrate the correct technique for applying an elastic bandage to a leg?
Correct Answer: B
Rationale: Starting at the distal end and moving toward the trunk promotes venous return and prevents constriction.