NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
Question 2 of 5
The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively?
Correct Answer: C
Rationale: The safe wall suction range for an adult is 80 to 120 mm Hg, making option 3 the action that is consistent with safe and effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds. The nurse should advance the catheter into the tracheostomy without occluding the Y-port to minimize mucosal trauma and aspiration of the client's oxygen.
Question 3 of 5
During an appointment with the nurse, a client says, 'I need to find the good,' the nurse responds, 'Oh, don't feel that way. We're making progress in these sessions.' The nurse's statement demonstrates a failure to do which of the following?
Correct Answer: A
Rationale: The nurse's response dismisses the client's statement, failing to explore its underlying meaning, which is essential for therapeutic communication.
Question 4 of 5
An I.V. infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?
Correct Answer: A
Rationale: Removing a small amount of hair may be necessary to secure the I.V. site on the scalp.
Question 5 of 5
Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a complete cardiac and respiratory arrest. This client has little of no chance for survival and they are facing imminent death according to your professional judgement, knowledge of pathophysiology and your critical thinking. You believe that all life saving measures for this client would be futile. What is the first thing that you, as the nurse, should do?
Correct Answer: B
Rationale: The client's advance directive clearly states a desire for all life-saving measures, including CPR and advanced cardiac life support. Despite the nurse's professional judgment about futility, the nurse is legally and ethically obligated to follow the advance directive and initiate CPR immediately in the event of a cardiac and respiratory arrest. Notifying the doctor or family or ensuring comfort are secondary actions after initiating life-saving measures as per the client's documented wishes.