NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
Question 2 of 5
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.
Question 3 of 5
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
Question 4 of 5
A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.
Question 5 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.