NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
Question 2 of 5
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
Correct Answer: C
Rationale: The Five Ps accurately describes a hand-off system with elements: patient, plan, purpose, problems, and precautions, used to ensure comprehensive communication during shift changes.
Question 3 of 5
The nurse has assisted the primary health care provider in placing a central (subclavian) catheter. Which priority action should the nurse take after the procedure?
Correct Answer: A
Rationale: A major risk associated with central catheter insertion is the possibility of a pneumothorax developing from an accidental puncture of the lung. Obtaining a chest radiograph and checking the results is the best method to determine if this complication has occurred and verify catheter tip placement before initiating intravenous (IV) therapy. Although a client may develop an infection at the central catheter site, a temperature elevation would not likely occur immediately after placement. Labeling the dressing site is important, but it is not a priority action in this situation. Although BP assessment is always important in checking a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
Question 4 of 5
A client with Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should instruct the client to:
Correct Answer: B
Rationale: Vitamin B6 can reduce the effectiveness of levodopa, so clients should avoid B6 supplements.
Question 5 of 5
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply.
Correct Answer: B,C,D
Rationale: Rapidly progressing numbness suggests a neurological condition like Guillain-Barré syndrome, requiring immediate provider notification (
B), monitoring for respiratory involvement with resuscitation equipment (
C), and ongoing assessment of paresthesia (
D). Family visits and ankle pumps are not priorities.