NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
Question 2 of 5
When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds?
Correct Answer: C
Rationale: Suctioning should not exceed 15 seconds to prevent hypoxia and trauma to the airway.
Question 3 of 5
The nurse is caring for a client with bipolar disorder in a manic phase. Which intervention is most appropriate?
Correct Answer: B
Rationale: A quiet environment reduces stimuli, helping to calm a client in a manic phase.
Question 4 of 5
You assess your family as having a deficit in terms of their instrumental activities of daily living (ADLs). Which healthcare professional would you most likely refer this family to in order to address this deficit?
Correct Answer: C
Rationale: Occupational therapists specialize in helping individuals improve their ability to perform instrumental activities of daily living (e.g., managing finances, cooking), making them the most appropriate referral for this deficit.
Question 5 of 5
Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to maintain the patient's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's order is not a substitute for a client's consent to release medical information in the absence of a communicable disease.
Correct Answer: A
Rationale: Reporting STDs to public health agencies is mandatory, but confidentiality must be maintained except in specific legal circumstances.