NCLEX-RN
Free NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
Question 2 of 5
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
Question 3 of 5
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
Question 4 of 5
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
Question 5 of 5
A client in ICU has a chest tube, and the nurse is assessing the chest tube drainage system. The nurse notices intermittent bubbling in the water seal chamber. What action should the nurse take?
Correct Answer: B
Rationale: Intermittent bubbling in the water seal chamber is normal during inspiration/expiration or coughing, indicating a patent system. It should be documented as a normal finding.