NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
Correct Answer: C
Rationale: Neomycin is an antibiotic, but this is not the rationale for administering it to a client in hepatic coma. Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted.
Question 2 of 5
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery.
To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
Question 3 of 5
A young boy tells the nurse, 'I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.' The nurse recognizes this stage of growth and development as:
Correct Answer: B
Rationale: The Oedipus complex involves a young boy's erotic attachment to his mother and jealousy toward his father.
Question 4 of 5
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:
Correct Answer: B
Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.
Question 5 of 5
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.