NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
You routinely use the PQRST method to assess pain. The PQRST method consists of:
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
Question 2 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 3 of 5
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
Question 4 of 5
A client reports having pain in his casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. Which action is most appropriate for the nurse to take at this time?
Correct Answer: D
Rationale: Swelling and unrelieved pain in a casted arm suggest possible compartment syndrome, requiring immediate physician notification. Elevating the arm or applying ice may help but is secondary to reporting.
Question 5 of 5
A client with a history of rheumatoid arthritis is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
Correct Answer: A, B, C, D, E
Rationale: Prednisone can cause hyperglycemia, osteoporosis, weight gain, hypertension, and hypokalemia.