NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.
Question 2 of 5
A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom?
Correct Answer: B
Rationale: Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Question 3 of 5
What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice?
Correct Answer: C
Rationale: Veracity is accurately paired with fully answering the client's questions without withholding information, as it emphasizes truthfulness in nursing practice. Justice involves fair treatment, not just equal time ; Beneficence involves promoting good, not just avoiding harm ; Fidelity is about keeping promises, not specifically the ANA Code .
Question 4 of 5
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
Question 5 of 5
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.