NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
When suctioning a client's tracheostomy tube, the nurse should incorporate which of the following steps into the procedure?
Correct Answer: A
Rationale: Pre-oxygenation prevents hypoxia during tracheostomy suctioning, ensuring client safety.
Question 2 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
Question 3 of 5
At a 6-month-old infant is being admitted from the emergency department with dehydration secondary to viral gastroenteritis. Which of the following room assignments is the most appropriate for this infant?
Correct Answer: C
Rationale: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room to prevent the spread of infection.
Question 4 of 5
The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
Question 5 of 5
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication should the nurse plan to prepare?
Correct Answer: B
Rationale: The manifestations of hypertensive crisis include hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The antidote for hypertensive crisis is phentolamine and a dosage by intravenous injection is administered. Protamine sulfate is the antidote for heparin. Calcium gluconate is used for magnesium overdose. Phytonadione is the antidote for warfarin overdose.