NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse in the emergency room is caring for a client with multiple rib fractures and a pulmonary contusion. Assessment reveals a respiratory rate of 38, a heart rate of 136, and restlessness. Which associated assessment finding would require immediate intervention?
Correct Answer: C
Rationale: Subcutaneous air and absent breath sounds suggest pneumothorax, requiring immediate intervention (e.g., chest tube). Hemoptysis (
A), wheezing (
B), and pain/rales (
D) are concerning but less urgent.
Question 2 of 5
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
Correct Answer: B
Rationale: This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.
Question 3 of 5
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
Correct Answer: C
Rationale: Increased PaCO2 is present in both acute and chronic respiratory acidosis due to hypoventilation. Decreased PaO2 may occur in respiratory acidosis but does not differentiate acute from chronic. Increased HCO3 indicates renal compensation, which occurs in chronic respiratory acidosis as the body attempts to buffer the excess CO2, but not in acute cases where compensation has not yet occurred. Decreased base excess is not specific to differentiating acute from chronic respiratory acidosis.
Question 4 of 5
The nurse is caring for a client with a history of a total knee replacement. The client complains of pain and swelling. The nurse should:
Correct Answer: A
Rationale: Ice reduces pain and swelling post-total knee replacement by decreasing inflammation. Elevation is helpful, aspirin requires an order, and notification is needed if symptoms persist.
Question 5 of 5
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
Correct Answer: A
Rationale: These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. Fluid intake should be increased to prevent dehydration. Environmental stimuli should be decreased to prevent precipitation of seizures. Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.