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 should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
Question 3 of 5
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.
Question 4 of 5
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
Question 5 of 5
The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when:
Correct Answer: A
Rationale: Instilling normal saline thins secretions, facilitating effective suctioning of the tracheostomy tube.