NCLEX Questions, RN NCLEX Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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RN NCLEX Practice Test Questions

Extract:


Question 1 of 5

A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:

Correct Answer: A

Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.

Question 2 of 5

The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?

Correct Answer: A

Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.

Question 3 of 5

A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Correct Answer: C

Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.

Question 4 of 5

Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.

Order the Items

Source Container

Suction the oral cavity.
Auscultate breath sounds for effectiveness.
Set suction control at 80-120 mm Hg.
Ambu or oxygenate at 100% O2
Apply suction while withdrawing the suction catheter.
Turn the head toward the side to be suctioned.
Auscultate breath sounds prior to suctioning.

Correct Answer: G, C, D, F, E, B, A

Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (
C), oxygenate (
D), turn head (F), apply suction (E), auscultate post-suction (
B), suction oral cavity (
A) to clean.

Question 5 of 5

The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?

Correct Answer: A

Rationale: Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.

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