NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
Question 2 of 5
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (
A) is unnecessary, high-fiber foods like nuts (
B) may cause blockages, and limiting fluids (
C) risks dehydration.
Question 3 of 5
The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?
Correct Answer: A
Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.
Question 4 of 5
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
Correct Answer: A
Rationale: This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
Question 5 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.