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
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
Correct Answer: B
Rationale: The chest tube should remain unclamped and disconnected from suction during transport to prevent tension pneumothorax, with the system kept below chest level.
Question 3 of 5
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
Correct Answer: C
Rationale: A recheck appointment confirms that the otitis media has resolved, ensuring no residual infection or complications.
Question 4 of 5
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
Question 5 of 5
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
Correct Answer: A
Rationale:
Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron and recommended for iron-deficiency anemia.