NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
Correct Answer: D
Rationale: Evisceration occurs when the incision separates and the contents of the cavity spill out.
Question 2 of 5
The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.
Question 3 of 5
Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities
Correct Answer: A
Rationale: Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.
Question 4 of 5
A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated, and receives mechanical ventilation. When performing suctioning, the nurse should:
Correct Answer: B
Rationale: Supplemental O2 should be administered before and after suctioning to reduce hypoxia.
Question 5 of 5
Nursing assessment of early evidence of septic shock in children at risk includes:
Correct Answer: A
Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.