NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.
Question 2 of 5
The nurse is observing a student gauss administering ear drops to a two-year-old. Which observation by the nurse would indicate correct technique?
Correct Answer: C
Rationale: Pulling the pinna down and back in children straightens the ear canal for proper ear drop administration. Head extension (
A), chin-tuck (
B), and irrigation (
D) are incorrect.
Question 3 of 5
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a full-strength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
Correct Answer: A
Rationale: Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding.
Question 4 of 5
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
Question 5 of 5
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.