NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis, suggesting inadequate ventilation and the need for mechanical ventilation. PCO2 58 (
A) and HCO3 30 (
D) are elevated but less critical, and SaO2 90 (
B) is low but not definitive.
Question 2 of 5
The client with cancer refuses to care for herself. Which action by the nurse would be best?
Correct Answer: C
Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.
Question 3 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 4 of 5
The nurse is caring for a newborn with a suspected diaphragmatic hernia. The nurse should:
Correct Answer: D
Rationale: Positioning a newborn with a diaphragmatic hernia on the affected side facilitates lung expansion on the unaffected side, improving respiration. Trendelenburg worsens breathing, and fluids are secondary.
Question 5 of 5
A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Correct Answer: D
Rationale: Diversion may help the child to focus on a pleasant activity instead of on his headache.