NCLEX RN Questions Nursing Fundamentals
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Question 1 of 5.
A nurse is caring for a client with pneumonia who is in bilateral wrist restraints for removing multiple peripheral vascular access devices. Upon assessment, the client developed agitation and increased confusion. The nurse should take which priority action?
A. Obtain vital signs
B. Release restraints and provide range of motion
C. Auscultate lung sounds
D. Assess skin integrity under each restraint
Explanation: Obtaining vital signs is the priority to assess for physiological causes of agitation and confusion, such as hypoxia or fever.
Question 2 of 5.
The nurse is observing a student nurse feed a client requiring aspiration precautions. The nurse should intervene if the student
A. Asks the client to remain sitting upright for at least 30 to 60 minutes after a meal.
B. Reminds the client to tilt their head backward when eating and drinking.
C. Avoids mixing foods of different textures in the same mouthful.
D. Places salt and pepper on the client's food at their request.
Explanation: Tilting the head backward increases aspiration risk. Upright positioning, avoiding mixed textures, and seasoning food are appropriate.
Question 3 of 5.
The nurse is caring for a client with increased intracranial pressure (ICP). The nurse plans on positioning the client's head of bed at
A. 25 degrees.
B. 30-40 degrees.
C. 10-20 degrees.
D. 5-10 degrees.
Explanation: A 30-40 degree elevation optimizes cerebral venous drainage, reducing ICP. Lower angles may increase ICP, and 25 degrees is suboptimal.
Question 4 of 5.
The nurse is teaching a client with hypothyroidism. The nurse should recommend that the client increase their intake of foods rich in
A. Fiber.
B. Saturated fats.
C. Calcium.
D. Potassium.
Explanation: Fiber aids digestion, often slowed in hypothyroidism. Saturated fats, calcium, and potassium are not specifically indicated.
Question 5 of 5.
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
A. Consume foods and liquids at room temperature.
B. Drink a large amount of fluid with meals.
C. Consume foods without aromas
D. Eat smaller portion sizes throughout the day.
E. Delay taking the prescribed antiemetic until the nausea is severe.
Explanation: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.
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