NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
Question 2 of 5
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
Correct Answer: B
Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.
Question 3 of 5
A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
Question 4 of 5
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
Correct Answer: A
Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (
Choice
B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (
Choice
C) or elevating the patient's leg (
Choice
D) may be necessary but do not address the immediate need for infection control measures.
Question 5 of 5
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
Correct Answer: C
Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (
Choice
A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (
Choice
B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (
Choice
D) is not relevant to the preparation process for an IVP.