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: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
Question 2 of 5
A client is very dependent on the staff but is able to make simple decisions. The client asks, 'Would you do my laundry? I don't know how the machine works.' Which of the following responses would be best?
Correct Answer: D
Rationale: Teaching the client to use the machine promotes independence while addressing their request.
Question 3 of 5
The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction.
Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
Question 4 of 5
You are asked by your supervisor to take photographs of the residents and their family members who are attending a holiday dinner and celebration at your long term care facility. What should you do?
Correct Answer: C
Rationale: Taking photographs without the explicit consent of all residents and family members violates their privacy rights under HIPAA . Consent must be obtained to ensure compliance with privacy regulations.
Question 5 of 5
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instruction in the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:
Correct Answer: A
Rationale: Teaching the client to monitor their radial pulse ensures they can detect irregularities or bradycardia, a critical aspect of managing digoxin therapy.