NCLEX RN· Full Length · NCLEX Practice Test RN
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
Expert Explanatory Rationale
Correct Answer: PH 7.23
The pediatric nurse charts that the parents of a 4-year-old child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
Expert Explanatory Rationale
Correct Answer: Refusing to participate in the child's care
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
Expert Explanatory Rationale
Correct Answer: Pain, pallor, pulselessness, paresthesia, and paralysis
A client with a history of a deep vein thrombosis is receiving Warfarin (Coumadin). The nurse should teach the client to avoid:
Expert Explanatory Rationale
Correct Answer: Green leafy vegetables
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
Expert Explanatory Rationale
Correct Answer: Mechanical ventilation
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
Expert Explanatory Rationale
Correct Answer: Respiratory depression
The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
Expert Explanatory Rationale
Correct Answer: Persistent sadness
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
Expert Explanatory Rationale
Correct Answer: Communicating the urge to defecate or urinate
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
Expert Explanatory Rationale
Correct Answer: Contact the physician
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
Expert Explanatory Rationale
Correct Answer: Cleanse the peristomal skin meticulously.