NCLEX Questions, NCLEX RN Practice Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Exam Questions

Extract:


Question 1 of 5

The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?

Correct Answer: D

Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.

Question 2 of 5

Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator-associated pneumonia?

Correct Answer: B

Rationale: CASS (continuous aspiration of subglottic secretions) tubes reduce ventilator-associated pneumonia by removing secretions.

Question 3 of 5

A client has received 10 mg of morphine sulfate subcutaneously. When does the nurse anticipate the maximal period of respiratory depression will occur?

Correct Answer: A

Rationale: Morphine sulfate administered subcutaneously reaches peak effect, including respiratory depression, within 5-10 minutes. Thus, 7 minutes (
A) is the most accurate time frame.

Question 4 of 5

The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?

Correct Answer: B

Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.

Question 5 of 5

A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?

Correct Answer: C

Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.

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