NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
Correct Answer: A, B, C, D, E, G
Rationale: Elevated commode seats (
A), removing rugs (
B), grab bars (
C), medic alert monitors (
D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
Question 2 of 5
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
Question 3 of 5
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?
Correct Answer: B
Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.
Question 4 of 5
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in dysphagia post-stroke. Thin liquids, flat positioning, and straws increase aspiration risk.
Question 5 of 5
A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?
Correct Answer: A
Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.