NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 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 2 of 5
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
Correct Answer: C
Rationale: Headaches may occur after taking nitroglycerin because of vasodilation. The tablets do not need to be refrigerated. The client should carry them with her. The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
Question 3 of 5
The nurse is assessing a client with suspected hypoglycemia. Which finding is most consistent with this condition?
Correct Answer: A
Rationale: Hypoglycemia causes sympathetic activation, leading to tremors and sweating as the body attempts to raise glucose levels. Chest pain, fever, and bradycardia are not typical.
Question 4 of 5
The nurse is caring for a client with a history of Alzheimer’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Alzheimer’s disease causes progressive memory impairment due to neuronal degeneration, a primary symptom of the condition.
Question 5 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.