NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
Question 2 of 5
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.
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
A client with a history of gout is admitted with joint swelling. The nurse should include which of the following in the plan of care?
Correct Answer: C
Rationale: Indomethacin reduces inflammation and pain in acute gout attacks.
Question 5 of 5
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.