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 admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
Question 3 of 5
A client has a prescription to begin short-term therapy with enoxaparin. The nurse explains to the client that this medication is being prescribed for which action?
Correct Answer: D
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected clients at risk. It is not used to treat urinary calculi, migraine headaches, or multiple sclerosis.
Question 4 of 5
You are asked by your supervisor to take photographs of the residents and their family members who are attending a holiday dinner and celebration at your long term care facility. What should you do?
Correct Answer: C
Rationale: Taking photographs without the explicit consent of all residents and family members violates their privacy rights under HIPAA . Consent must be obtained to ensure compliance with privacy regulations.
Question 5 of 5
The nurse assesses a client scheduled for a thyroidectomy for psychosocial problems that may cause preoperative anxiety. Considering the nature of the surgery which client fear is a realistic source of anxiety?
Correct Answer: D
Rationale: Because the incision is in the neck area, the client may be fearful of having a large scar postoperatively. Sexual dysfunction and infertility could possibly occur if the entire thyroid gland is removed, and the client is not placed on thyroid replacement medications. The client will not have specific dietary restrictions after discharge. Having all or part of the thyroid gland removed will not cause gynecomastia or hirsutism.