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 who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
Question 3 of 5
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
Question 4 of 5
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
Correct Answer: A
Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
Question 5 of 5
The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.