NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
Question 2 of 5
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
Question 3 of 5
A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
Question 4 of 5
Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
Question 5 of 5
You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer's disease. You are planning a session on the stages of Alzheimer's disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session?
Correct Answer: B
Rationale: The Reisberg Scale (Global Deterioration Scale) indicates that in the first stage, individuals with Alzheimer's may cover up their failing abilities, which is an important point to include for caregivers to understand early disease behaviors.