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Free NCLEX RN PDF with 30 questions
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The PDF includes 30 NCLEX RN questions with answers and explanations.
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Q1You are assisting the physician with removal of a chest tube. The nurse should instruct the patient to:
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✓ Correct answer: Perform the Valsalva’s maneuver.
The nurse should instruct the patient to perform the Valsalva’s maneuver (take a deep breathe, exhale and bear down). Then the tube would be quickly removed and an airtight dressing placed. An alternative would be to ask the patient to take a deep breathe and hold the breath while the tube is removed.
Q2A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. <br/><br/>This client should avoid which of the following?
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✓ Correct answer: Caffeine-containing products
Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods are not restricted but high-calorie foods are.
Q3Which should the nurse anticipate including in the care plan for a client the first 24 hours post thyroidectomy?
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✓ Correct answer: Suction oral secretions as necessary.
Oral secretions may need to be suctioned following a thyroidectomy.<br/><br/>A pillow is used to support the head and neck after surgery, and the client should avoid neck extension because it may disrupt the surgical site.<br/><br/>The client may experience a moderate amount of serosanguinous drainage in the first 24 hours.<br/><br/>The client will place both hands behind their neck before coughing to support the neck and reduce tension on the suture line.<br/><br/>If the dressing around the neck becomes too tight (choice C), this may be an indication of a complication that could impede the airway.<br/><br/>The client should immediately be assessed for hemorrhage or any respiratory compromise and the health care provider notified immediately.<br/><br/>Emergency tracheostomy equipment (not thoracentesis equipment as choice D indicates) should be kept immediately available.
Q4The diet for your patient who is suffering from uremic syndrome would include all of the following EXCEPT:
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✓ Correct answer: High nitrogen foods
Nitrogen and potassium would be limited. The patient would be provided a limited but high-quality protein diet and a limited sodium, nitrogen, potassium, and phosphate diet.
Q5The nurse is providing education for a client scheduled for a myringotomy. <br/><br/>Which statement made by the client indicates an understanding of the information?
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✓ Correct answer: "I will avoid bending over for the next three weeks."
The client making the statement in choice B understands the information the nurse has provided.<br/><br/>The client should not bend over for the following three weeks to avoid increasing middle ear pressure, which may disrupt the surgical site.<br/><br/>Further education may be necessary if the client makes the statements in choices A, C, and D.<br/><br/>The client should be instructed to avoid drinking through a straw because the increased pressure may disrupt the surgical site.<br/><br/>Some drainage is an expected finding for the first few days post-surgery.<br/><br/>The client will be instructed to change the dressing every 24 hours and immediately report excessive drainage.<br/><br/>The client will be instructed to avoid blowing his or her nose with the mouth closed to prevent an increase in the pressure.
Q6A nurse carries out the physician’s order for a 24-hour urine collection. After explaining the procedure to the client, which of the following actions of the client indicates they understood the instructions?
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✓ Correct answer: Discards the first voided urine.
The first voided urine should be discarded when collecting a 24-hour urine specimen. A 24-hour urine test is done to determine the total volume of urine the client’s body can produce in 24 hours. The urine is also tested for certain substances such as protein, urea nitrogen, and aldosterone. The other remaining options are incorrect steps that would result in inaccurate results.
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