NCLEX Questions, NCLEX RN Practice Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Exam Questions

Extract:


Question 1 of 5

The nurse is caring for an elderly female client in an extended care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate?

Correct Answer: B

Rationale: Standing in front of the client maximizes her ability to see the nurse, as dry AMD affects central vision, making clear visual communication essential.

Question 2 of 5

The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:

Correct Answer: D

Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.

Question 3 of 5

When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?

Correct Answer: A

Rationale: Restraints are justified for current dangerous behavior (
A) posing immediate risk to self or others. History of falls (
B), past violence (
C), or non-cooperation (
D) do not warrant restraints.

Question 4 of 5

The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST?

Correct Answer: B

Rationale: indicates chest pain, needs to seek medical attention immediately

Question 5 of 5

The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:

Correct Answer: B

Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.

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