NCLEX-RN
Free NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
Question 2 of 5
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring efficacy while minimizing toxicity; a level of 20 mcg/mL is within this range.
Question 3 of 5
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
Question 4 of 5
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
Question 5 of 5
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
Correct Answer: B
Rationale: The nurse violated HIPAA by allowing the filming of other clients without their consent, as this discloses protected health information (PHI) without authorization.