NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
Question 2 of 5
A client with bipolar disorder is admitted during a depressive episode. Which intervention should the nurse prioritize?
Correct Answer: B
Rationale: During a depressive episode, monitoring for suicidal ideation is the priority to ensure client safety, given the high risk of suicide in bipolar depression.
Question 3 of 5
A 17-year-old client has been admitted to the hospital for a biopsy to confirm the diagnosis of bone cancer. The nurse should assess the client for which conditions? Select all that apply.
Correct Answer: C,D,E,F,G
Rationale: Bone cancer may cause pain, swelling, fever, anorexia, and decreased range of motion due to tumor effects on bone and surrounding tissues. Cough and dyspnea are less common unless metastasis occurs.
Question 4 of 5
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
Question 5 of 5
The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure?
Correct Answer: A
Rationale: The percutaneous approach uses local anesthesia. Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually. There is usually no need for anticoagulant therapy after surgery.