NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). The nurse should expect the client to have:
Correct Answer: A
Rationale: COPD causes air trapping, leading to a barrel chest due to hyperinflated lungs.
Question 2 of 5
A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Using an electric razor prevents the risk of cuts while shaving. Any physician or dentist should be informed of anticoagulant therapy because of the risk of bleeding due to a prolonged PT. The client should be instructed to consult with his physician. Aspirin is avoided because it potentiates the effects of oral anticoagulants by interfering with platelet aggregation. Identification bracelets are necessary to direct treatment, especially in an emergency situation.
Question 3 of 5
The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
Correct Answer: B
Rationale: A high-calorie, low-fat diet supports recovery from pancreatitis by reducing pancreatic stimulation while meeting energy needs. High-fat diets exacerbate symptoms, and low-calorie diets are inadequate.
Question 4 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 5 of 5
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel decompression. When preparing to insert a NG tube, the nurse measures from the:
Correct Answer: D
Rationale: This measurement is ~50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement is ~50 cm (47-48 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-ear-xiphoid). This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.