NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TC
A). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.
Question 2 of 5
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
Question 3 of 5
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
Question 4 of 5
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
Question 5 of 5
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.