NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is caring for a client post-thyroidectomy. Which finding indicates a potential complication?
Correct Answer: A
Rationale: Hoarseness post-thyroidectomy may indicate recurrent laryngeal nerve damage, a serious complication requiring immediate reporting.
Question 3 of 5
The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction.
Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
Question 4 of 5
The nurse is caring for a client with a history of glaucoma. Which of the following medications should the nurse expect to administer?
Correct Answer: A, C, D
Rationale: Timolol, pilocarpine, and latanoprost are used to reduce intraocular pressure in glaucoma. Atropine is contraindicated as it increases pressure.
Question 5 of 5
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
Correct Answer: A,B,C
Rationale:
To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.