NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
Correct Answer: C
Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
Question 2 of 5
The nurse is caring for a client with a history of a total knee replacement. The client complains of pain and swelling. The nurse should:
Correct Answer: A
Rationale: Ice reduces pain and swelling post-total knee replacement by decreasing inflammation. Elevation is helpful, aspirin requires an order, and notification is needed if symptoms persist.
Question 3 of 5
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?
Correct Answer: D
Rationale: (A,
B) This statement can be answered with a simple yes or no. This statement is asked in a negative manner and therefore has a negative connotation. This statement is open ended and positively stated.
Question 4 of 5
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Question 5 of 5
The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?
Correct Answer: B
Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (
A) suggests heart failure, cramping (
C) is nonspecific, and pale/cool foot (
D) indicates arterial occlusion.