NCLEX-RN
Free NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
Question 2 of 5
The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?
Correct Answer: A
Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.
Question 3 of 5
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
Question 4 of 5
Which of the following actions does NOT require the use of standard precautions?
Correct Answer: C
Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.
Question 5 of 5
Lochia serosa usually is evident on days 4 to 10 postpartum. When teaching the client about postpartum care, how should the nurse describe lochia serosa?
Correct Answer: C
Rationale: Lochia serosa, days 4-10 postpartum, is pinkish to brownish (
C) due to decreased blood and increased serous fluid. Dark red (
A) is lochia rubra, yellowish (
B) or clear (
D) are not typical.