NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
Question 2 of 5
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
Question 3 of 5
You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the client and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer's disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband?
Correct Answer: B
Rationale: Educating the wife about Alzheimer's disease and promoting the husband's independence as much as possible supports safety and dignity while respecting her role as a caregiver with physical limitations.
Question 4 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Theophylline can cause tachycardia due to its stimulant effects.
Question 5 of 5
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.