NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
Correct Answer: B
Rationale: Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
Question 2 of 5
The nurse is caring for a newborn with a suspected diaphragmatic hernia. The nurse should:
Correct Answer: D
Rationale: Positioning a newborn with a diaphragmatic hernia on the affected side facilitates lung expansion on the unaffected side, improving respiration. Trendelenburg worsens breathing, and fluids are secondary.
Question 3 of 5
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
Correct Answer: B
Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.
Question 4 of 5
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery.
To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
Question 5 of 5
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.