NCLEX-PN
NCLEX PN Practice Questions Questions
Extract:
Question 1 of 5
Following a cholecystectomy, drainage from the client's T tube for the first 24 hours after the operation was 350 cc. What is the appropriate nursing action?
Correct Answer: D
Rationale: T-tube drainage of 300–500 mL in the first 24 hours post-cholecystectomy is expected as bile drains externally. Continuing to observe and measure is appropriate unless other signs of complications arise.
Question 2 of 5
The nurse is performing tracheal suctioning and notes a previously used bottle of saline at the client's bedside. The nurse should:
Correct Answer: B
Rationale: A new, sterile saline bottle is required for suctioning to prevent infection. Reusing or relabeling an opened bottle is unsafe.
Question 3 of 5
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
Correct Answer: C
Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.
Question 4 of 5
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
Correct Answer: A
Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.
Question 5 of 5
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.