NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
Correct Answer: D
Rationale: A low-carbohydrate diet prevents a hypertonic bolus, reducing dumping syndrome. The other options exacerbate the condition.
Question 2 of 5
The nurse is teaching a client with a history of type 2 diabetes about foot care. The nurse should tell the client to:
Correct Answer: A
Rationale: Daily foot inspection helps detect early signs of injury or infection in type 2 diabetes, preventing complications like ulcers.
Question 3 of 5
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery.
To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
Question 4 of 5
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
Question 5 of 5
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
Correct Answer: C
Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.