NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
Correct Answer: C
Rationale: Pursed-lip breathing helps blow off CO2 and keep air passages open, reducing shortness of breath. Increasing O2 too high may remove the breathing stimulus, and the other options are not appropriate.
Question 2 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which finding would require the nurse to withhold the dose?
Correct Answer: A
Rationale: Digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as bradycardia increases the risk of toxicity. The other findings are within normal ranges for digoxin administration.
Question 3 of 5
The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.
Question 4 of 5
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
Correct Answer: B
Rationale: It is sufficient to rinse the plastic holders with warm water at least once per day. It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. 'Neutralizing' the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.
Question 5 of 5
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
Order the Items
Source Container
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).