NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 of 5
A client in the recovery ICU is on mechanical ventilation. The nurse notices the client has frothy secretions around his mouth, and the nurse hears adventitious breath sounds with the stethoscope. The nurse should
Correct Answer: B
Rationale: Frothy secretions and adventitious sounds suggest airway obstruction or pulmonary edema. Suctioning clears the endotracheal tube, improving ventilation.
Question 2 of 5
A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan?
Correct Answer: A
Rationale: An INR of 8.0 indicates a high risk of bleeding, so assessing for abnormal bleeding is the priority intervention.
Question 3 of 5
Twenty-four hours after an uncomplicated labor and delivery, a client's WBC is 12,000 cu/mm. The elevation in the client's WBC is most likely an indication of:
Correct Answer: A
Rationale: A WBC of 12,000 cu/mm post-delivery is a normal physiological response to the stress of labor and delivery.
Question 4 of 5
A 56-year-old male with a long history of alcohol abuse is brought to the detox center per terms of his probation. He had his last drink 6 hours ago and seems confused and agitated. The nurse expects the physician to order
Correct Answer: B
Rationale: Chlordiazepoxide (Librium), a benzodiazepine, is used to manage alcohol withdrawal symptoms like confusion and agitation, preventing seizures.
Question 5 of 5
The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air from entering the pleural space, which is the priority action for a dislodged chest tube.