NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 of 5
A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
Question 2 of 5
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client:
Correct Answer: B
Rationale: Encouraging activity, stress reduction, and fatigue management supports the client's quality of life and symptom control. Inactivity, changing disease course, or premature focus on aids are less appropriate.
Question 3 of 5
A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
Question 4 of 5
A 62-year-old male is dying from metastatic lung cancer, and all treatments have been discontinued. The client's breathing pattern is labored, with gurgling. The client's wife asks the nurse, 'Can't you do something to help with his breathing?' Which of the following is the nurse's best response in this situation?
Correct Answer: C
Rationale: Repositioning, elevating the head of the bed, and using a cool compress can alleviate labored breathing and gurgling (death rattle) in a dying client, providing comfort without invasive measures.
Question 5 of 5
The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:
Correct Answer: D
Rationale: Massaging reddened bony prominences is contraindicated, as it can damage fragile tissue and reduce blood flow, worsening the risk of pressure ulcers.