NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Question 1 of 5
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
Question 2 of 5
Your client is receiving phototherapy. What nursing intervention would you implement for this client?
Correct Answer: B
Rationale: Phototherapy, often used for jaundice, can affect stool color (e.g., green or loose stools in infants). Monitoring stool color helps assess treatment effects and complications.
Question 3 of 5
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.
Question 4 of 5
A client with a history of gout is prescribed probenecid. The nurse should instruct the client to:
Correct Answer: A, B
Rationale: Increased fluid intake prevents kidney stones, and aspirin can reduce probenecid's effectiveness.
Question 5 of 5
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.