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
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
Question 3 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 4 of 5
The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?
Correct Answer: B
Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.
Question 5 of 5
The nurse is assisting a primary health care provider with abdominal paracentesis. What position should the nurse assist the client into for this procedure?
Correct Answer: C
Rationale: For abdominal paracentesis, the nurse should position the client in either a semi-Fowler's position or an upright position on the edge of the bed with the feet resting on a stool and the back well supported. This position allows the intestine to float posteriorly and helps prevent laceration during catheter insertion. None of the remaining options suggest the correct position.