NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse instructs a female client about collecting a midstream urine sample for culture and sensitivity. Which should the nurse include in client teaching?
Correct Answer: B
Rationale:
To prepare properly for collection of a sterile urine specimen, the client cleanses the perineum from front to back using antiseptic swabs. Bathing before a midstream urine collection is unnecessary; however, proper specimen handling is critically important because improper specimen handling can yield inaccurate test results. The specimen should be labeled with the client's name, date, time, and medical record number in addition to the provider's name. The client should begin the flow of urine and collect the sample after starting the flow of urine, and then send the specimen to the laboratory as soon as possible.
Question 2 of 5
Which statement about total parenteral nutrition is true?
Correct Answer: C
Rationale: The Valsalva maneuver is used when changing TPN tubing to prevent air embolism by increasing intrathoracic pressure.
Question 3 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 4 of 5
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
Question 5 of 5
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.