NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
Correct Answer: A
Rationale: The water seal prevents air from entering the pleural space, maintaining negative pressure for lung re-expansion.
Question 2 of 5
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.
Question 3 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?
Correct Answer: A
Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.
Question 4 of 5
A client with polycythemia vera is admitted with complaints of difficulty breathing and pleuritic pain. Which lab finding is expected in the client with polycythemia vera?
Correct Answer: A
Rationale: Polycythemia vera is characterized by excessive red blood cell production, leading to an increased red blood cell count, which can cause hyperviscosity and symptoms like dyspnea.
Question 5 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.