NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
Question 2 of 5
The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the I.V. pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. Which of the following is not appropriate to do by the nurse when recognizing that the previous dose was not administered 8 hours ago to the client with pneumonia?
Correct Answer: A
Rationale: Discarding the medication without investigation is inappropriate; the nurse should verify, document, and address the error appropriately.
Question 3 of 5
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for? Select all that apply.
Correct Answer: A, B, C, D
Rationale: Burns can cause sepsis (infection), hypovolemia (fluid loss), hyperkalemia (tissue damage), and respiratory distress (inhalation injury).
Question 4 of 5
The nurse identifies the type of presentation shown in the fi gure as which of the following?
Correct Answer: C
Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.
Question 5 of 5
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.