NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply.
Correct Answer: B,E
Rationale: Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus.
Question 2 of 5
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.
Question 3 of 5
A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication?
Correct Answer: A
Rationale: Betamethasone, a corticosteroid, is administered to increase the surfactant level and increase fetal lung maturity, reducing the incidence of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks' gestation. If adequate amounts of surfactant are not present in the lungs, respiratory distress and death are possible consequences. Delivery needs to be delayed for at least 48 hours after the administration of betamethasone in order to allow time for the lungs to mature. The remaining options are incorrect.
Question 4 of 5
You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?
Correct Answer: D
Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.
Question 5 of 5
When creating a program to decrease the primary cause of disability and death in children, which of the following is most effective for the community health nurse to do?
Correct Answer: B
Rationale: Free immunizations address the leading cause of preventable childhood disability and death by ensuring widespread protection against infectious diseases.