NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
Question 2 of 5
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
Question 3 of 5
A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.
Question 4 of 5
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
Question 5 of 5
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
Correct Answer: A
Rationale: This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.