NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.
Question 2 of 5
The nurse is caring for a client with a chest tube. Which finding indicates a potential complication?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate attention.
Question 3 of 5
The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?
Correct Answer: B
Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
Question 4 of 5
The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
Question 5 of 5
A client with rheumatoid arthritis reports morning stiffness. Which intervention should the nurse recommend?
Correct Answer: C
Rationale: A warm shower in the morning increases blood flow and reduces joint stiffness, a common symptom of rheumatoid arthritis.