NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
Question 2 of 5
A client with a history of depression is prescribed venlafaxine (Effexor). The nurse should instruct the client to report which of the following side effects immediately?
Correct Answer: B
Rationale: Venlafaxine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
Question 3 of 5
A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor the client for which of the following electrolyte imbalances?
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring.
Question 4 of 5
Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed?
Correct Answer: A
Rationale: Oral hygiene removes residual tube-related irritation and promotes comfort after NG tube removal.
Question 5 of 5
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.