NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction.
Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
Question 2 of 5
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
Question 3 of 5
When using crutches, the client should be instructed to bear weight primarily on the:
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.
Question 4 of 5
The nurse is caring for a client with a history of liver cirrhosis who is prescribed lactulose (Cephulac). The nurse should expect the client to experience which of the following effects?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, preventing hepatic encephalopathy.
Question 5 of 5
You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?
Correct Answer: D
Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.