NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
Question 2 of 5
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.
Question 3 of 5
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
Question 4 of 5
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
Question 5 of 5
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.