NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
Question 2 of 5
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
Correct Answer: A
Rationale: The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If enough solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse needs to report these symptoms. The conditions noted in the other options are not complications of the procedure.
Question 3 of 5
A client is admitted with acute glomerulonephritis. The nurse should monitor the client for which of the following?
Correct Answer: A, D
Rationale: Acute glomerulonephritis can cause hypertension (due to fluid retention) and hypoalbuminemia (due to proteinuria).
Question 4 of 5
The best way to objectively evaluate the effectiveness of an individual staff member's time management skills in a longitudinal manner is to:
Correct Answer: D
Rationale:
To objectively evaluate time management skills over time, collecting, aggregating, and analyzing outcome data provides a longitudinal perspective on whether the staff member consistently completes assignments within the allotted time. This method is more objective than single-shift observations (A,
B) or self-reports .
Question 5 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.