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 deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
Question 2 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 3 of 5
The nurse is teaching a client with a new diagnosis of multiple sclerosis about safety precautions. Which of the following instructions is most important?
Correct Answer: A
Rationale: Using assistive devices prevents falls, a critical safety concern in multiple sclerosis due to muscle weakness or coordination issues.
Question 4 of 5
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
Question 5 of 5
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.