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NCLEX RN Practice Questions

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Question 1 of 5

While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:

Correct Answer: A

Rationale: A fundus displaced to the right suggests bladder distention, which can be resolved by asking the client to void.

Question 2 of 5

The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

Correct Answer: C

Rationale: Covering the insertion site with Vaseline gauze prevents air from entering the pleural space, which is the priority action for a dislodged chest tube.

Question 3 of 5

The nurse is instructing a client who has had an eye removed in the proper procedure for inserting a prosthetic eye. Place the following steps of prosthetic-eye insertion (in Roman numerals) in the correct sequence from the first to the last.

Order the Items

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Raise the upper eyelid.
Pull the lower eyelid down.
Slide the prosthesis under and behind the upper eyelid.
Identify landmarks on the prosthetic eye for the inner and outer areas and the superior and inferior aspects.
Check the positioning.
Cleanse the prosthetic eye according to the manufacturer's directions.

Correct Answer: F,D,A,B,C,E

Rationale: The correct sequence for inserting a prosthetic eye is: Cleanse the prosthetic eye (VI), identify landmarks (IV), raise the upper eyelid (I), pull the lower eyelid down (II), slide the prosthesis under the upper eyelid (III), and check positioning (V). This ensures proper hygiene and alignment.

Question 4 of 5

A client has had a central catheter inserted for administration of parenteral nutrition. An X-ray was taken to ensure correct positioning prior to commencing infusions. The X-ray report indicates that the catheter tip is in the right atrium. Which of the following actions by the nurse is correct?

Correct Answer: A

Rationale: Catheter tip in the right atrium is too far; infusion should be held and the MD notified (
A) for repositioning. Adjusting the catheter (B,
D) or starting infusion (
C) is unsafe.

Question 5 of 5

The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

Correct Answer: B

Rationale: Nausea is a common sign of amphotericin B toxicity, often accompanied by fever and chills.

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