logo

NCLEX Questions Leadership and Management

Home / Nursing & Allied Health Certifications / NCLEX RN

Review
Practice
Exam

Question 1 of 5.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who is

A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C).

B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side.

C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous.

D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.

Explanation: Absent breath sounds with a chest tube for pneumothorax (B) indicate a life-threatening complication, such as tube dislodgement or re-collapse, requiring immediate assessment. A fever post-hypophysectomy (A) suggests infection but is less urgent. Nervousness from albuterol (C) is a common side effect, and cramping during dialysis (D) is less critical unless severe.

Question 2 of 5.

The nurse has received the following information about assigned clients. The nurse should first assess the client with

A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).

B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.

C. diabetes mellitus who refuses to eat following the administration of glargine insulin.

D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.

Explanation: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.

Question 3 of 5.

The nurse is caring for a client who is asking about advanced directives. Many documents fall under the category of an advanced directive. The nurse knows that one of the most common legal papers is called 'Durable Power of Attorney for Health Care' and works to:

A. Review a person's personal preferences for medical care in the future.

B. Authorize another person to make medical decisions for a person if they become unable to on their own.

C. Assign a legal authority in making medical decisions while honoring the spoken word of the family.

D. Define what care should be administered or withheld by health care professionals, no matter which medical facility the patient finds themselves in.

Explanation: A Durable Power of Attorney for Health Care (B) authorizes a designated person to make medical decisions if the client is incapacitated. Reviewing preferences (A) describes a living will. Honoring family wishes (C) is not legally binding, and defining care across facilities (D) overstates its scope.

Question 4 of 5.

The nurse is demonstrating effective prioritization for assigned clients. Place the actions in the order in which they need to be performed, starting with the highest priority.

Explanation: 1. Suctioning an endotracheal tube (C) ensures airway patency, a life-saving priority. 2. Administering antihypertensives (D) prevents cardiovascular complications. 3. Sterile dressing change (B) prevents infection but is less urgent. 4. Bronchodilator (E) improves breathing but is long-acting, less time-sensitive. 5. Incident report (A) is administrative and not urgent.

Question 5 of 5.

The nurse has become aware of the following client situations. The nurse should first follow up with the client who

A. has an irregular pulse and is receiving treatment for atrial fibrillation.

B. has influenza and had an increase in temperature to 102°F (39°C).

C. is receiving nebulizer treatments for asthma that suddenly stops wheezing.

D. has an indwelling urinary catheter and reports burning at the insertion site.

Explanation: Sudden cessation of wheezing in asthma (C) may indicate severe airway obstruction, a life-threatening emergency. Irregular pulse (A), fever with influenza (B), and catheter burning (D) are concerning but less immediately critical.

Unlock your Potential. Subcribe to access more

GET IN TOUCH

+012 345 67890

support@examlin.com

Privacy

Terms

FAQS

Help


© Examlin.All Rights Reserved.