NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
Question 2 of 5
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
Correct Answer: A
Rationale: Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuous pull on the extremity. A sling is used instead of pins. Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.
Question 3 of 5
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
Correct Answer: B
Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
Question 4 of 5
A 1000-mL dose of D5W 1/2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 125 gtt/min.
Question 5 of 5
A client has recently been diagnosed with primary open-angle glaucoma. The nurse should tell the client to avoid taking:
Correct Answer: B
Rationale: Benadryl, an antihistamine, can increase intraocular pressure, worsening primary open-angle glaucoma, so it should be avoided.