NCLEX RN· Full Length · NCLEX RN Practice
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
A client has returned from having a bronchoscopy. Before offering the client sips of water, the nurse should assess the client's:
Expert Explanatory Rationale
Correct Answer: Gag reflex
A tornado warning has been issued in the area surrounding the hospital. Which action by the nurse is most appropriate to ensure client safety?
Expert Explanatory Rationale
Correct Answer: close blinds, roll client beds out into the hallway, and close the doors to all the rooms
The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?
Expert Explanatory Rationale
Correct Answer: A 21-year-old male with a fractured femur
The physician has ordered lab work for a client with suspected disseminated intravascular coagulation (DIC). Which lab finding would provide a definitive diagnosis of DIC?
Expert Explanatory Rationale
Correct Answer: Presence of fibrin split compound
An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:
Expert Explanatory Rationale
Correct Answer: Keep crackers at the bedside for eating before she arises
The nurse would recognize which symptom as the most likely early indication of pneumonia in an elderly client?
Expert Explanatory Rationale
Correct Answer: altered mental status
The nurse is reviewing labs on a client receiving IV heparin and notes an INR of 4.6. Which order by the health care provider does the nurse anticipate?
Expert Explanatory Rationale
Correct Answer: an order for protamine sulfate
A client diagnosed with gout 10 years ago admits she has never treated her gout and hoped it would just go away. The nurse knows all of the following are potential complications from untreated gout EXCEPT
Expert Explanatory Rationale
Correct Answer: peripheral neuropathy.
The nurse is admitting a new client to the medical unit. When asked about advance directives, the client says, 'I'm not really sure what that is, but I trust my doctor to do whatever he thinks I need.' Which is the correct action by the nurse?
Expert Explanatory Rationale
Correct Answer: explain what advance directives are and how they benefit the client, and offer to give the client a copy so she can read it and ask questions
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?
Expert Explanatory Rationale
Correct Answer: Beefy tongue
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