NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The sudden onset of which of the following indicates a potentially serious complication for the client receiving an I.V. infusion?
Correct Answer: A
Rationale: Noisy respirations may indicate fluid overload or pulmonary edema, a serious I.V. infusion complication requiring immediate intervention.
Question 2 of 5
The physician has ordered a low-potassium diet for a client. Which of the following food choices indicates that the client needs further instruction regarding the diet?
Correct Answer: B
Rationale: Baked potatoes are high in potassium, so choosing them indicates a need for further teaching on a low-potassium diet.
Question 3 of 5
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.
Question 4 of 5
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
Correct Answer: A,B,C
Rationale:
To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
Question 5 of 5
The nurse is assessing a client with a suspected pulmonary embolism. Which of the following symptoms is most likely to be present?
Correct Answer: B
Rationale: Sudden chest pain is a common symptom of pulmonary embolism due to impaired blood flow to the lungs.