NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
Question 2 of 5
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring.
Question 3 of 5
Which site or technique would you expect to use to administer ferrous sulfate?
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
Question 4 of 5
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
Question 5 of 5
A client has been given a prescription for propantheline as adjunctive treatment for peptic ulcer disease. How should the nurse tell the client to take this medication?
Correct Answer: D
Rationale: Propantheline is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes before meals to reduce acid secretion before food intake stimulates gastric acid production. Administering with meals or just after meals would reduce its effectiveness, and taking it with antacids could interfere with its absorption.