NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications?
Correct Answer: C,D
Rationale: TPN can cause hyperglycemia due to high glucose content and infection due to catheter use, both requiring vigilant monitoring.
Question 2 of 5
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, 'How could God do this to me? I've never done anything wrong.' Which of the following responses by the nurse would be most appropriate at this time?
Correct Answer: B
Rationale: Acknowledging the client's anger and the difficulty of the loss validates their emotions and provides empathetic support, which is most appropriate in this situation. Option A may dismiss the client's feelings, C shifts focus inappropriately, and D assumes strength without addressing the emotional impact.
Question 3 of 5
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.
To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
Question 4 of 5
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.
Question 5 of 5
Which test result should the nurse review to determine the compatibility of blood from two different donors?
Correct Answer: D
Rationale: The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs) and is the screening component of a prescription to 'type and screen' a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The Rh factor is determined at the same time as the ABO type. The direct Coombs' test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client's RBCs.