NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
Question 2 of 5
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
Question 3 of 5
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Excessive alcohol use, gallstones, abdominal trauma, and hyperlipidemia with high triglycerides are established risk factors for pancreatitis, as they can disrupt塌 or obstruct pancreatic ducts or cause inflammation.
Question 4 of 5
You routinely use the PQRST method to assess pain. The PQRST method consists of:
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
Question 5 of 5
A client with a burn injury is prescribed silver sulfadiazine. What should the nurse monitor for?
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia, so monitoring white blood cell counts is essential.