NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?
Correct Answer: A
Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.
Question 2 of 5
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
Question 3 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.
Question 4 of 5
The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.
Question 5 of 5
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.