NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?
Correct Answer: B
Rationale: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.
Question 2 of 5
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
Question 3 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 4 of 5
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.
Question 5 of 5
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.