NCLEX RN· Full Length · NCLEX RN Test Bank with Rationales
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason?
Expert Explanatory Rationale
Correct Answer: To provide essential fatty acids
Lipids are a brand of intravenous fat emulsion administered to clients who are at risk for developing an essential fatty acid deficiency, such as those receiving TPN. Fat emulsions help meet caloric and nutritional needs that cannot be met by glucose administration alone. Fat emulsions are not administered to increase the amount of body fluids and they do not decrease the incidence of phlebitis.
Fat emulsions neither replace TPN nor do they require infusion during the night.
A client with a history of gout is admitted with joint swelling. The nurse should include which of the following in the plan of care?
Expert Explanatory Rationale
Correct Answer: Administer indomethacin as prescribed.
Indomethacin reduces inflammation and pain in acute gout attacks.
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?
Expert Explanatory Rationale
Correct Answer: Using calm, firm directions to get the client to a quiet room.
Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
Expert Explanatory Rationale
Correct Answer: Reposition the client to a high Fowler's position.
Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
Expert Explanatory Rationale
Correct Answer: Inserting the airway with the tip pointed upward
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.
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?
Expert Explanatory Rationale
Correct Answer: Ensure that a chest radiograph is done.
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.
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
Expert Explanatory Rationale
Correct Answer: Report fever or yellowing of skin
Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
A client with a history of anxiety is prescribed buspirone (Buspar). The nurse should teach the client that the medication:
Expert Explanatory Rationale
Correct Answer: Takes 2 to 4 weeks to be effective
Buspirone requires 2 to 4 weeks to achieve therapeutic effects for anxiety, unlike benzodiazepines, which act quickly.
A client is scheduled for an intravenous pyelogram (IVP). Which of the following questions would be most important for the nurse to ask the client in preparation for the procedure?
Expert Explanatory Rationale
Correct Answer: Do you have any allergies to shellfish?'
Shellfish allergies may indicate a risk for contrast dye reactions, critical for IVP safety.
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
Expert Explanatory Rationale
Correct Answer: The Five Ps: The patient, plan, purpose, problems and precautions
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.
Start Your NCLEX RN Preparation Journey Today
Access over 300,000 verified practice questions, comprehensive subject diagnostic exams, and timed clinical simulations engineered for success.