NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
Correct Answer: C
Rationale: Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression.
Question 2 of 5
When you are monitoring your client who is now started on an intravenous antibiotic for an infection, you notice that the client is exhibiting signs of anaphylaxis. What is your first priority intervention?
Correct Answer: A
Rationale: Stopping the IV flow is the first priority to halt the administration of the allergen causing anaphylaxis, followed by other emergency interventions.
Question 3 of 5
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What should the nurse determine based on this finding?
Correct Answer: D
Rationale: The water-seal chamber should be filled to the 2-cm mark to provide an adequate water seal between the external environment and the client's pleural cavity. The water seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding sterile water until the level is again at the 2-cm mark. The other interpretations are incorrect.
Question 4 of 5
The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced?
Correct Answer: C
Rationale: The description of the seizure, with the entire body becoming rigid (tonic phase) followed by alternating relaxation and contraction of muscles in all four extremities (clonic phase), is characteristic of a tonic-clonic seizure. Partial seizures involve only a portion of the body or brain, absence seizures are brief lapses in awareness without significant motor activity, and complex partial seizures involve altered consciousness with automatisms, none of which match the described symptoms.
Question 5 of 5
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.