NCLEX RN Test Bank with Rationales
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?
A. You must insure that the client has a patent intravenous catheter that is at least 20 gauge.
B. You will need the help of another nurse prior to the administration of these packed red blood cells.
C. The unit of packed red blood cells should start no more than 1 hour after it is picked up.
D. You must remain with and monitor the client for at least 30 minutes after the transfusion begins.
Explanation: 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.
What is the primary goal of multidisciplinary case conferences?
A. To fulfill the nurse's role in terms of collaboration
B. To plan and provide for optimal client outcomes
C. To solve complex multidisciplinary patient care problems
D. To provide educational experiences for experienced nurses
Explanation: The primary goal of multidisciplinary case conferences is to plan and provide for optimal client outcomes by bringing together various professionals to coordinate care and address the client's needs holistically.
Question 3 of 5.
Select the standardized 'hand off' change of shift reporting system that is accurately paired with its elements.
A. SBAR: Symptoms, background, assessment and recommendations
B. ISBAR: Interventions, symptoms, background, assessment and recommendations
C. The Five Ps: The patient, plan, purpose, problems and precautions
D. BATON: Background, assessment, timing, ownership and next plans
Explanation: 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 4 of 5.
Legal prohibitions against sharing passwords are legally based on:
A. The Security Rule
B. The American Nurses Association's Code of Ethics
C. The American Hospital's Patients' Bill of Rights
D. The Autonomy Rule
Explanation: Legal prohibitions against sharing passwords are based on the Security Rule of HIPAA, which mandates safeguards to protect electronic protected health information.
Question 5 of 5.
Which statement about referrals is accurate?
A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
B. Referrals simply allow the client to be discharged into the community with the additional care they need.
C. Nurses facilitate referrals to only the resources within the facility.
Explanation: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
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