NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
Question 2 of 5
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
Question 3 of 5
A client with a history of heart failure is admitted with dyspnea. Which position should the nurse place the client in?
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure clients with dyspnea.
Question 4 of 5
Your client is receiving phototherapy. What nursing intervention would you implement for this client?
Correct Answer: B
Rationale: Phototherapy, often used for jaundice, can affect stool color (e.g., green or loose stools in infants). Monitoring stool color helps assess treatment effects and complications.
Question 5 of 5
You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client's past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others?
Correct Answer: D
Rationale: Establishing trust is the first step in de-escalating potential violence, as it fosters a therapeutic relationship and reduces the client's anxiety or agitation, which could otherwise escalate into violent behavior.