NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
You will be administering packed red blood cells to your client. Which of the following principles should you apply to this blood administration?
Correct Answer: D
Rationale: Monitoring the client for at least 15-30 minutes after starting a transfusion is critical to detect acute reactions like hemolysis or allergic responses.
Question 2 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 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
In the early postoperative period, the nurse notes a bright red, 3' x 5' area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
Correct Answer: C
Rationale: Bright red drainage suggests active bleeding, so taking vital signs to assess for hemodynamic instability is the priority.
Question 5 of 5
The nurse is caring for a client with a history of peptic ulcer disease who is prescribed misoprostol (Cytotec). The nurse should instruct the client to take the medication:
Correct Answer: A
Rationale: Misoprostol should be taken with meals to reduce gastrointestinal side effects and protect the stomach lining.