NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery.
To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
Question 2 of 5
The client with cancer refuses to care for herself. Which action by the nurse would be best?
Correct Answer: C
Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.
Question 3 of 5
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
Question 4 of 5
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
Question 5 of 5
When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?
Correct Answer: A
Rationale: Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.