NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.
Question 2 of 5
A client diagnosed with chronic kidney disease has been prescribed epoetin alfa. The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy?
Correct Answer: A
Rationale:
To form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate stores of iron, folic acid, and vitamin B12. The client should take these ferrous gluconate supplements regularly to enhance the hematocrit-raising benefit of this medication. The other options are unnecessary medications.
Question 3 of 5
A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply.
Correct Answer: B,E
Rationale: Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus.
Question 4 of 5
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.
Correct Answer: A,D,E
Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.
Question 5 of 5
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.