NCLEX-RN
RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?
Correct Answer: A
Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (
A). Notifying the physician (
B) or encouraging coughing (
C) is secondary, and irrigation (
D) is not typically the initial step.
Question 2 of 5
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
Question 3 of 5
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
Correct Answer: C
Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.
Question 4 of 5
A client with Crohn's disease requires TPN to provide adequate nutrition. The nurse finds the TPN bag empty. What fluid would the nurse select to hang until another bag is prepared in the pharmacy?
Correct Answer: C
Rationale: D10W provides dextrose to prevent hypoglycemia, a risk when TPN (high in glucose) is abruptly stopped. Saline or other fluids don't provide necessary glucose.
Question 5 of 5
A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?
Correct Answer: C
Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.