NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.
Question 2 of 5
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
Question 3 of 5
A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?
Correct Answer: B
Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (
A) is incorrect, pain-based use (
C) is wrong, and refrigeration (
D) is unnecessary.
Question 4 of 5
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
Question 5 of 5
A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
Correct Answer: A
Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (
A) is priority. Samples (
B), teaching (
C), and financial aid (
D) are inappropriate without resolving the contraindication.