NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority during tracheostomy care?
Correct Answer: A
Rationale: Cleaning the inner cannula with sterile technique prevents infection and maintains airway patency, a priority. Dressings (
B), suctioning (
C), and tie changes (
D) are secondary.
Question 2 of 5
One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
Correct Answer: A
Rationale: Taking furosemide early in the day minimizes nighttime urination, reducing fall risk. The other options increase nighttime bathroom trips or are irrelevant to fall prevention.
Question 3 of 5
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.
Question 4 of 5
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
Question 5 of 5
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.