NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
Correct Answer: C
Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.
Question 2 of 5
The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.
Question 3 of 5
Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?
Correct Answer: B
Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.
Question 4 of 5
A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
Correct Answer: B
Rationale: Warfarin affects clotting, requiring monitoring of PT/INR to ensure therapeutic anticoagulation. Platelets (
A), hemoglobin (
C), and potassium (
D) are not directly affected.
Question 5 of 5
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.