NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Question 1 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 2 of 5
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.
Question 3 of 5
The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
Question 4 of 5
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
Question 5 of 5
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.