NCLEX-RN
Free NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
Question 2 of 5
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
Question 3 of 5
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
Correct Answer: C
Rationale: The proximal end of a double-barrel colostomy, which produces stool, is typically on the client's right side.
Question 4 of 5
The nurse is caring for a client hospitalized with nephotic syndrome. Based on the client's treatment, the nurse should:
Correct Answer: D
Rationale: Nephrotic syndrome causes fluid retention, but adequate hydration is needed to maintain renal perfusion, so offering additional fluids is appropriate.
Question 5 of 5
The nurse is assessing a client with suspected glomerulonephritis. Which of the following findings would the nurse expect?
Correct Answer: B
Rationale: hematuria and proteinuria are hallmark signs of glomerulonephritis due to glomerular damage