NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
Question 2 of 5
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
Question 3 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 4 of 5
An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
Correct Answer: A
Rationale: Urine specific gravity is unrelated to assessing for ileus, which involves monitoring bowel sounds, stool characteristics, and gastric output to detect gastrointestinal function.
Question 5 of 5
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
Correct Answer: B
Rationale: Aminophylline, a bronchodilator, is effective when it relaxes bronchial smooth muscles, improving airflow in emphysema.