NCLEX Questions, NCLEX RN Practice Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Exam Questions

Extract:


Question 1 of 5

A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?

Correct Answer: D

Rationale: Denial of grief, as indicated by acting like nothing has happened, suggests abnormal grieving, as it may reflect an inability to process the loss.

Question 2 of 5

The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for:

Correct Answer: A

Rationale: After administering naloxone, the nurse should assess for pupillary changes, as reversal of opioid effects can cause sympathetic stimulation, affecting pupil size.

Question 3 of 5

Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator-associated pneumonia?

Correct Answer: B

Rationale: CASS (continuous aspiration of subglottic secretions) tubes reduce ventilator-associated pneumonia by removing secretions.

Question 4 of 5

The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

Correct Answer: C

Rationale: Unexplained weight loss is a common symptom of leukemia due to increased metabolic demand and systemic effects of the disease.

Question 5 of 5

The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:

Correct Answer: B

Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.

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