NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.
Question 2 of 5
The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client's symptoms, the nurse should suspect which complication of central line use?
Correct Answer: B
Rationale: Sudden dyspnea, chest pain, and confusion post-central line removal suggest an air embolus, a serious complication requiring immediate intervention.
Question 3 of 5
The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
Correct Answer: A
Rationale: Raisins are lower in potassium compared to oranges, apricots, and bananas, making them suitable for a low-potassium diet.
Question 4 of 5
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
Question 5 of 5
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (
A), administering naloxone (
C) to reverse effects, providing oxygen (
D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (
B) is not immediate.