NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
Question 2 of 5
A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply.
Correct Answer: B,E
Rationale: Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus.
Question 3 of 5
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.
Question 4 of 5
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
Question 5 of 5
The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure?
Correct Answer: A
Rationale: The percutaneous approach uses local anesthesia. Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually. There is usually no need for anticoagulant therapy after surgery.