NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
Correct Answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma.
Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
Question 2 of 5
A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer's disease. The woman tells the nurse that she wants to try ginkgo biloba for her father before using prescription medications. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: The appropriate response is to acknowledge the client's wishes and communicate them to the physician for consideration. It is important to be culturally sensitive and respect the client's preferences. Ginkgo biloba has shown some benefits in treating dementia, so it is essential to involve the healthcare provider in the decision-making process.
Choices A, B, and C are dismissive and fail to consider the client's perspective and cultural beliefs. It is crucial for healthcare professionals to engage in open communication and collaboration with clients to provide patient-centered care.
Question 3 of 5
Signs of internal bleeding include all of the following except:
Correct Answer: C
Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage.
Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.
Question 4 of 5
Which of the following lab values is associated with a decreased risk of cardiovascular disease?
Correct Answer: B
Rationale: High HDL cholesterol is associated with a decreased risk of cardiovascular disease because HDL cholesterol is known as 'good' cholesterol. It helps remove other forms of cholesterol, like LDL cholesterol, from the bloodstream, reducing the risk of plaque buildup in the arteries. Low HDL cholesterol (
Choice
B) is actually a risk factor for cardiovascular disease because it means there is less of the 'good' cholesterol to perform its protective functions. Low total cholesterol (
Choice
C) and low triglycerides (
Choice
D) are not necessarily associated with a decreased risk of cardiovascular disease, as the balance and types of cholesterol play a more crucial role in heart health.
Question 5 of 5
A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
Correct Answer: D
Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.