NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-MI due to ischemic damage to the conduction system. Hypertrophy develops later, and hyperkalemia is less common.
Question 2 of 5
A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes?
Correct Answer: D
Rationale: The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.
Question 3 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: A
Rationale: High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C,
D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
Question 4 of 5
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Correct Answer: A
Rationale: A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. Proper identification of the recipient and the blood product must be validated by at least two people.
Question 5 of 5
The nurse is caring for a client with a history of a hip fracture who is in Buck’s traction. The nurse should:
Correct Answer: C
Rationale: In Buck’s traction, weights must hang freely off the floor to maintain proper traction force. Turning is limited, traction is not removed, and lotion is unnecessary.