NCLEX-RN
NCLEX RN Practice Exam Questions
Extract:
Question 1 of 5
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
Question 2 of 5
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.
Question 3 of 5
The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
Correct Answer: A
Rationale: Isoniazid can interact with tyramine-rich foods like tuna, causing adverse effects (e.g., hypertension). Selecting tuna casserole indicates ineffective teaching. The other foods are safe.
Question 4 of 5
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (
A) posing immediate risk to self or others. History of falls (
B), past violence (
C), or non-cooperation (
D) do not warrant restraints.
Question 5 of 5
The nurse is caring for a 7-year-old child with constipation. The child's mother asks the nurse what she can do to help prevent another episode. What information would the nurse include in her response?
Correct Answer: D
Rationale: Encouraging regular toilet habits after meals promotes bowel regularity without relying on invasive or inappropriate measures like enemas or excessive milk.