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
A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
Question 3 of 5
The nurse is caring for a client who has just undergone a cholecystectomy. Which of the following positions is most appropriate for this client in the immediate postoperative period?
Correct Answer: B
Rationale: Semi-Fowler's position promotes lung expansion and reduces pressure on the surgical site after cholecystectomy.
Question 4 of 5
A nurse is caring for a client with a new colostomy. Which of the following actions should the nurse include in the teaching plan to prevent skin breakdown around the stoma?
Correct Answer: A
Rationale: A skin barrier protects the peristomal skin from irritation caused by stool. Soap can irritate the skin, leaving the pouch off risks exposure, and petroleum jelly is not recommended.
Question 5 of 5
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.