NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
Correct Answer: A,B,C,E,F,G
Rationale: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.
Question 2 of 5
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
Question 3 of 5
A client is scheduled for an intravenous pyelogram (IVP). Which of the following questions would be most important for the nurse to ask the client in preparation for the procedure?
Correct Answer: B
Rationale: Shellfish allergies may indicate a risk for contrast dye reactions, critical for IVP safety.
Question 4 of 5
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Vaginal bleeding may indicate endometrial cancer, a serious side effect of tamoxifen, requiring immediate reporting.
Question 5 of 5
The nurse instructs the client in mixing and administering regular and NPH insulin. Which of the following statements indicates that the client needs additional instruction?
Correct Answer: B
Rationale: Shaking NPH insulin can damage it; it should be gently rolled. Drawing up regular insulin first, cool storage, and a 90-degree injection angle are correct practices.