NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
Immediately after the client receives an injection of bupivacaine (Marcaine), he becomes restless and nervous and reports a feeling of impending doom. Which of the following actions by the nurse is appropriate at this time?
Correct Answer: C
Rationale: Restlessness, nervousness, and a feeling of impending doom after bupivacaine injection may indicate systemic toxicity or an allergic reaction, requiring immediate vital sign assessment to guide further action. Talking, reassurance, or administering epinephrine without assessment is premature.
Question 2 of 5
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.
Question 3 of 5
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
Question 4 of 5
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
Question 5 of 5
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.