NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.
Question 2 of 5
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?
Correct Answer: D
Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.
Question 3 of 5
The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?
Correct Answer: C
Rationale: Evaluating restraint incidents aims to improve procedures, ensuring safer and more effective use in the future. Documentation and calming down are secondary, and resolving feelings is not the primary goal.
Question 4 of 5
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.
Question 5 of 5
A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.