NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.
Correct Answer: A,D,E
Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.
Question 2 of 5
The nurse is caring for a client post-thyroidectomy. Which finding indicates a potential complication?
Correct Answer: A
Rationale: Hoarseness post-thyroidectomy may indicate recurrent laryngeal nerve damage, a serious complication requiring immediate reporting.
Question 3 of 5
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
Question 4 of 5
You are caring for a group of clients who are adversely affected with phobias. Which form of group therapy will you most likely employ to treat these clients?
Correct Answer: C
Rationale: Cognitive behavioral psychotherapy (CBT) is the most effective treatment for phobias, as it combines cognitive restructuring with behavioral techniques like exposure therapy to address irrational fears.
Question 5 of 5
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?
Correct Answer: D
Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.