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NCLEX Practice Exam Questions with 100% Correct Answers
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NCLEX Practice Exam Questions with 100% Correct Answers The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determi...

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  • 12 oktober 2024
  • 87
  • 2024/2025
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Voorbeeld van de inhoud

©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
NCLEX Practice Exam Questions with

100% Correct Answers


The nurse cares for the client diagnosed with a pneumothorax resulting

from a motor vehicle accident three days ago. The client has a chest tube

connected to a three-chamber water-seal drainage system with 20 cm

suction. The nurse determines the lung has re-expanded if which

observation is made?



1. There is no drainage in the collection chamber for 3 hours

2. The fluid in the water-seal chamber does not fluctuate with respirations

3. There is continuous bubbling in the water-seal chamber

4. There is gentle bubbling in the suction-control chamber - ✔✔2. The

fluid in the water-seal chamber does not fluctuate with respirations



Rationale: Indicates no more air leaking into pleural space

The 18-month old is admitted to the unit with a diagnosis of

laryngotracheobronchitis (LTB). During the initial assessment, the nurse

expects to find which early symptoms?

,©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.

1. Kussmaul respirations and bradycardia

2. Elevated temperature and slow respiratory rate

3. Expiratory wheezing and substernal retractions

4. Inspiratory stridor and restlessness - ✔✔4. Inspiratory stridor and

restlessness



Rationale: LTB or croup syndrome is characterized by edema and

inflammation of upper airways. The inspiratory strider is often the first

observable symptom of LTB.

The health care provider inserts a temporary pacemaker in a client

following a myocardial infarction. The nurse knows that which outcome is

the primary purpose of the pacemaker?



1. Increases the force of myocardial contraction

2. Increases the cardiac output

3. Prevents premature ventricular contractions (PVCs)

4. Prevents systemic overload - ✔✔2. Increases the cardiac output

,©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
Rationale: A pacemaker acts to regulate cardiac rhythm. This can be atrial,

or ventricular, or both chambers. The outcome of the intervention is to

increase the cardiac output.

The client in labor is monitored with an internal fetal monitor. The nurse

knows which is the most important reason for the fetal monitor?



1. To evaluate the progress of the client's labor

2. To assess the strength and duration of the client's contractions

3. To monitor the oxygen status of the fetus during labor

4. To determine if an oxytocin drip is necessary - ✔✔3. To monitor the

oxygen status of the fetus during labor



Rationale: Goal is early detection of mild fetal hypoxia

The nurse prepares an older client for an intravenous pyelogram (IVP). The

client asks the nurse to explain the reason why the procedure is performed.

The nurse's response is based on which explanation?



1. The HCP is able to directly observe the kidney pelvis

2. An IVP assess the glomerular filtration rate

3. The HCP is able to examine the urinary tract by x-ray

, ©JOSHCLAY 2024/2025. YEAR PUBLISHED, 2024.
4. Medication is injected into the urinary system - ✔✔3. The HCP is able

to examine the urinary tract by x-ray



Rationale: During an IVP, x-rays are taken of the entire urinary tract and

helps evaluate kidney function.

The nurse cares for the client admitted with cerebral vascular accident

(CVA) and facial paralysis. Nursing care is planned to prevent which

complication?



1. Inability to talk

2. Loss of the gag reflex

3. Inability to open the affected eye

4. Corneal abrasion - ✔✔4. Corneal abrasion



Rationale: A client will be unable to close the affected eye voluntarily when

facial nerve is affected. The lacrimal gland will no longer supply secretions

that protect the eye and can cause a corneal abrasion. Nursing care will

include cool compresses and prescribed eye drops.

A school-age child client is in the early stages of nephrotic syndrome. The

nurse discusses which protein adjustments with the parents?

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