NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
Question 2 of 5
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
Question 3 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
Question 4 of 5
Which of the following statements best explains why the nurse should evaluate gastric residual in administering the client's next enteral feeding?
Correct Answer: C
Rationale: Evaluating gastric residual prevents overdistention of the stomach, which can lead to aspiration or discomfort. It does not directly assess nutrient absorption or feeding adequacy.
Question 5 of 5
The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that:
Correct Answer: B
Rationale: Cystic fibrosis is an autosomal recessive disorder, meaning two carrier parents have a $25\%$ chance of having a child with the disease, as each parent can pass on the defective gene.