NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse’s INITIAL priority when managing a physically assaultive client is to
Correct Answer: C
Rationale: most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client’s self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client
Question 2 of 5
A client who has just undergone a laparoscopic cholecystectomy complains of 'free air pain.' What would be your best action?
Correct Answer: A
Rationale: Free air pain' after laparoscopic cholecystectomy is due to residual carbon dioxide in the abdomen. Ambulation helps disperse the gas and relieve pain.
Question 3 of 5
A nursing student is assigned to a client with an endotracheal tube on a ventilator. Upon entering the client's room the primary care nurse is alerted by observing which of the following?
Correct Answer: C
Rationale: Normal saline at the bedside may indicate improper suctioning practices, as it’s not recommended for routine endotracheal suctioning, posing a risk for infection.
Question 4 of 5
One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
Correct Answer: A
Rationale: Sock and mitten burns (circumferential burns on hands and feet) are inconsistent with a fall into a bathtub and suggest immersion, raising suspicion of abuse.
Question 5 of 5
A nurse starts an IV medication for a client. It is ordered as IV push, and she pushes the medication slowly over two minutes. The client then becomes restless, complains of chest pain, has difficulty breathing, and becomes cyanotic. The nurse recognizes this is most likely caused by
Correct Answer: D
Rationale: Rapid onset of chest pain, dyspnea, cyanosis, and restlessness after IV push suggests pulmonary embolism, likely from air or thrombus introduced during administration.