NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
Question 2 of 5
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
Question 3 of 5
A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
Question 4 of 5
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, 'How could God do this to me? I've never done anything wrong.' Which of the following responses by the nurse would be most appropriate at this time?
Correct Answer: B
Rationale: Acknowledging the client's anger and the difficulty of the loss validates their emotions and provides empathetic support, which is most appropriate in this situation. Option A may dismiss the client's feelings, C shifts focus inappropriately, and D assumes strength without addressing the emotional impact.
Question 5 of 5
A client has been taking lisinopril for 3 months. The client reports to the nurse a persistent dry cough that began about 1 month ago. The nurse interprets that the most likely reason for the client's complaint is what?
Correct Answer: B
Rationale: A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the primary health care provider if the cough becomes very troublesome to them. The other options are incorrect interpretations.