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
The nurse is assessing a client with suspected meningitis. Which finding requires immediate action?
Correct Answer: A
Rationale: Nuchal rigidity is a critical sign of meningitis, indicating meningeal irritation and requiring immediate medical intervention to prevent complications.
Question 3 of 5
The mother calls the nurse to report that her toddler has just been burned on the arm. The nurse should advise the mother to first:
Correct Answer: C
Rationale: Running cool water over the burn reduces tissue damage and pain, followed by wrapping in a clean cloth to protect the area before seeking medical care.
Question 4 of 5
A client taking clozapine (Clozaril) states, 'I think I'm getting the flu. I have a fever and feel weak.' Which of the following should the nurse do next?
Correct Answer: D
Rationale: Fever and weakness in a client taking clozapine may indicate agranulocytosis, a serious side effect, requiring immediate physician notification after confirming the temperature.
Question 5 of 5
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.