NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
Question 2 of 5
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
Question 3 of 5
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.
Question 4 of 5
A client with a history of heart failure is admitted with worsening symptoms. The nurse should monitor the client for which of the following laboratory abnormalities? Select all that apply.
Correct Answer: A, C, E
Rationale: Heart failure can cause hyponatremia (fluid overload), elevated BNP (cardiac stress), and elevated creatinine (renal impairment).
Question 5 of 5
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.