NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a new tracheostomy about home care. Which of the following instructions should be included? Select all that apply.
Correct Answer: A, B, D, E
Rationale: Daily cleaning, suctioning, keeping a spare tube, and using a humidifier are essential for tracheostomy care. Tube changes are typically done by professionals.
Question 2 of 5
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first?
Correct Answer: C
Rationale: The first action would be to apply the oxygen because the client can be experiencing myocardial ischemia. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, oxygen is the priority to prevent further cardiac damage. Drawing the blood specimens would be done after oxygen administration and just before or after the ECG, depending on the situation. Although the chest x-ray can show cardiac enlargement, having the chest x-ray would not influence immediate treatment.
Question 3 of 5
A client with type 1 diabetes mellitus is admitted with symptoms of hyperglycemia. Which laboratory finding should the nurse expect?
Correct Answer: C
Rationale: Hyperglycemia in type 1 diabetes often leads to diabetic ketoacidosis, with ketones in the urine due to fat metabolism, a key finding to monitor.
Question 4 of 5
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
Question 5 of 5
A mother is concerned about the amount of snacking her teenage boy is doing. She is concerned that this behavior could lead to obesity. Which of the following is an appropriate percentage of the daily diet to be obtained from snacks?
Correct Answer: B
Rationale: Snacks should contribute about 25% of daily caloric intake to balance nutrition without leading to excessive weight gain.