NCLEX Questions, NCLEX Trainer Test 10 Questions, NCLEX-PN Questions, Nurselytic

Questions 227

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Question 1 of 5

A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to

Correct Answer: A

Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space

Question 2 of 5

A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?

Correct Answer: B

Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report

Question 3 of 5

The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate?

Correct Answer: B

Rationale: Irritability and restlessness suggest a paradoxical reaction to chloral hydrate, requiring physician notification for medication adjustment. Options A, C, and D are unsafe or ineffective.

Question 4 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?

Correct Answer: D

Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.

Question 5 of 5

The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?

Correct Answer: B

Rationale: surgical consent should be rechecked prior to going to surgery

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