NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
When caring for a ventilator-dependent client who is receiving tube feedings, the nurse can help prevent aspiration of gastric secretions by:
Correct Answer: B
Rationale: Elevating the head of the bed 30-45° reduces the risk of aspiration in ventilator-dependent clients.
Question 2 of 5
On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, 'I feel numbness and my face is twitching.' What is the nurse's best initial action?
Correct Answer: C
Rationale: Numbness and facial twitching suggest hypocalcemia due to parathyroid gland damage during thyroidectomy, requiring immediate physician notification for calcium supplementation.
Question 3 of 5
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
Correct Answer: A
Rationale: Leaving the stethoscope in the room prevents MRSA transmission, as it avoids contaminating other areas or clients.
Question 4 of 5
A client is scheduled for hemodialysis twice weekly through an arteriovenous fistula in the left arm. Following each hemodialysis treatment, the nurse should evaluate the client for which of the following because of risks associated with hemodialysis? Select all that apply.
Correct Answer: A,C
Rationale: Hemodialysis risks include fluid volume deficit (
A) from rapid fluid removal and bleeding (
C) from the fistula site. Fluid excess (
B) and pulmonary edema (E) are pre-dialysis risks, and acidosis (
D) is corrected by dialysis.
Question 5 of 5
The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:
Correct Answer: B
Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.