NCLEX NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. When teaching the client with tuberculosis about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct answer: Liver function
Rationale: The nurse should emphasize the importance of monitoring liver function tests in clients taking INH due to the risk of hepatocellular injury and hepatitis associated with this medication. Regular assessment of liver enzymes can help detect liver damage early. Monitoring kidney function, blood sugar levels, or cardiac enzymes is not specifically required for clients taking INH and tuberculosis treatment.
2. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?
- A. Wash the wound with cleanser, rinse, and pat dry
- B. Bind the wound tightly, secure with tape, and elevate the foot
- C. Contact the physician after the dressing change is complete
- D. Provide analgesics for the client after the procedure
Correct answer: Wash the wound with cleanser, rinse, and pat dry
Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.
3. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?
- A. Ask where the client obtained the alcohol.
- B. Locate the alcoholic substance.
- C. Convey empathy and support to the client.
- D. Document the client's drinking behavior.
Correct answer: Locate the alcoholic substance.
Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.
4. A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
- A. Administer 2 ventilations
- B. Perform a head-tilt, chin lift to open the airway
- C. Begin chest compressions
- D. Perform a jaw thrust to open the airway
Correct answer: C: Begin chest compressions
Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
5. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct answer: Right cephalic vein
Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.
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