NCLEX Questions, RN NCLEX Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

RN NCLEX Practice Questions Questions

Extract:


Question 1 of 5

A student nurse is precepting on the unit and caring for a client with a Dobbhoff nasoenteric tube. Which statement by the student nurse indicates the need for further teaching on caring for a client with this tube? Select all that apply.

Correct Answer: B, C

Rationale: Auscultation is not a reliable method for confirming tube placement; X-ray is required. Mixing medications with feedings can cause clogs or interactions. The other statements are correct.

Question 2 of 5

Which task should be assigned to the nursing assistant?

Correct Answer: C

Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.

Question 3 of 5

The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?

Correct Answer: B

Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.

Question 4 of 5

The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:

Correct Answer: A

Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.

Question 5 of 5

A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?

Correct Answer: B

Rationale: The left antecubital fossa is suitable as it is away from burned areas (hands, right arm, face, neck) and provides a large vein for IV access.

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