NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
Correct Answer: D
Rationale: Lying on the affected side can compress the chest tube, obstructing drainage and risking pneumothorax or tension pneumothorax, requiring immediate repositioning. Continuous bubbling in the water seal is expected initially, and the other findings are appropriate.
Question 2 of 5
A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?
Correct Answer: A
Rationale: A WBC of 14,000 cu.mm indicates possible infection or inflammation, which is concerning pre-surgery and should be reported. Abdominal bruit and lower back pain are expected with an abdominal aortic aneurysm, and a platelet count of 175,000 is normal.
Question 3 of 5
The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
Question 4 of 5
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery.
To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
Question 5 of 5
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
Correct Answer: C
Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.