NCLEX-RN
RN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.
Question 2 of 5
A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.
Question 3 of 5
A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
Correct Answer: B
Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.
Question 4 of 5
The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply.
Correct Answer: C,D
Rationale: A healthy stoma is reddish-pink, moist, and protrudes slightly (
D). Initial stools are liquid, becoming formed over time (
C). Function typically starts in 2-5 days, not 24 hours (
A), and significant bleeding (
B) is abnormal.
Question 5 of 5
A client is confused after receiving morphine for analgesia and repeatedly tries to pull out the intravenous (IV) line in her left arm. Which of the following actions is the best initial solution?
Correct Answer: A
Rationale: Camouflaging the IV and providing a safe alternative (
A) is a least-restrictive, non-invasive initial approach to prevent the client from pulling out the IV. Restraints (B,
C) should be a last resort, and discontinuing the IV (
D) is unnecessary.