NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Question 1 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 2 of 5
The infusion rate of total parenteral nutrition is tapered before being discontinued. This is done to prevent which of the following complications?
Correct Answer: C
Rationale: Tapering TPN prevents rebound hypoglycemia by allowing the body to adjust to reduced glucose infusion.
Question 3 of 5
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.
Question 4 of 5
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
Question 5 of 5
A client with a history of multiple sclerosis is prescribed interferon beta-1a (Avonex). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Depression is a serious side effect of interferon beta-1a, requiring immediate reporting due to the risk of worsening mental health.