NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
Correct Answer: C
Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.
Question 2 of 5
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and
A), and zinc. Baked chicken breast (protein), broccoli (vitamin
C), wheat roll (carbohydrates), and an orange (vitamin
C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).
Question 3 of 5
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
Question 4 of 5
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
Correct Answer: C
Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.
Question 5 of 5
A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:
Correct Answer: B
Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.