NCLEX Practice Test RN
Question 1 of 5.
A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to:
A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more times to complete the series every 1-2 hours while awake
B. Purse the lips and take quick, short breaths approximately 18-20 times/min
C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose. Repeat 4-5 times to complete the series
D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
Explanation: This is the correct method of teaching diaphragmatic breathing, which allows full lung expansion to increase oxygenation, prevent atelectasis, and move secretions up and out of the lungs to decrease risk of pneumonia. Quick, short breaths do not allow for full lung expansion and movement of secretions up and out of the lungs. Quick, short breaths may lead to O2 depletion, hyperventilation, and hypoxia. Expelling breaths through the nose does not allow for full lung expansion and the use of diaphragmatic muscles to assist in moving secretions up and out of the lungs. Inhaling and exhaling at a rate of 20-24 times/min does not allow time for full lung expansion to increase oxygenation. This would most likely lead to O2 depletion and hypoxia.
Question 2 of 5.
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
A. Oral itching after eating bananas
B. Swelling of the eyes and mouth
C. Difficulty in breathing
D. Swelling and itching of the hands
Explanation: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
Question 3 of 5.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
A. Libel
B. Slander
C. Malpractice
D. Negligence
Explanation: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
Question 4 of 5.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
A. Decreased blood pressure and constricted pupils
B. Increased heart rate and increased respirations
C. Increased respirations and increased blood pressure
D. Anoxia and absence of the cough reflex
Explanation: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
Question 5 of 5.
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
A. Assess the drainage bag.
B. Check for bladder distention.
C. Unclamp the tubing.
D. Irrigate the tubing.
Explanation: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.