Free Nclex Exam Practice Question 2024
Nclex Exam Practice Question 2024
1. Nurse Ramya is advised to provide continuous enteral feed to his client. Which among the following action by nurse indicate lack of knowledge in this area?
a. Providing fowlers position to the client
b. Administering feeds at room temperature
c. Maintain prescribed flow rate
d. Hang the complete feed for one day
Ans. (d) Hang the complete feed for one day
Explanation: Continuous enteral nutrition: gravity administered or by feeding pump continuously for 12 hrs/day or more. Except option d, all other options are correct related to continuous enteral feed.
2. Nurse Janet is educating a client regarding sublingual medication administration. Which statement by the client shows need for teaching?
a. These are the medications administered on the floor of the mouth
b. These medications are absorbed directly into blood stream from the oral mucosa
c. These medications bypass the GI and hepatic system
d. These are the medications given on top of the tongue
Ans. (d) These are the medications given on top of the tongue
Explanation: Sublingual administration means medications are administered under the tongue to dissolve and for easy and early absorption. They are not administered on the top of the tongue.
3. Nurse Joisha is caring for a client in postoperative unit with Jackson-Pratt wound drain in situ. Which of the following action performed by nurse Jisha is correct regarding the care of drain site?
a. Clean the drain site from inner to outer in circular motion
b. Clean the drain site from outer to inner with a linear stroke
c. Remove the drain and clean the site
d. Wear all PPE while providing drain site care
Ans. (a) Clean the drain site from inner to outer in circular motion
Explanation: Drain site is considered as clean and the site has to be cleaned from inner to outer (more clean to less clean area) using circular strokes. Cleaning from outer to inner and the removal of drain and cleaning the site are also not recommended. While cleaning the drain site, one needs to wear sterile gloves rather than
4. Which among the following nursing diagnosis is most important
while caring for a female client with deep vein thrombosis?
a. Risk for injury related to increased venous blood flow
b. Altered tissue perfusion related to venous congestion
c. Fluid volume overload related to edema
d. Risk for infection due to altered skin integrity
Ans. (b) Altered tissue perfusion related to venous congestion
Explanation: Deep vein thrombosis leads to decreased tissue perfusion. So most appropriate nursing diagnosis is altered tissue perfusion related to venous congestion.
5. Nurse John is reviewing his nursing care plan for the assigned client and decided to revise the nursing care plan for his client. In which step of the nursing process revision takes place?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
Ans. (d) Evaluation
Explanation: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved and evaluates the success of the plan. Assessment involves data collection. Planning involves setting priorities, and implementation is the actual intervention.
6. Nurse Alice working in recovery room received a client following cholecystectomy surgery. Which among the following nursing diagnosis takes highest priority in the immediate post-operative period?
a. Impaired skin integrity due to surgical incision
b. Fluid volume deficit related to blood loss during surgery
c. Risk for aspiration related to general anesthesia
d. Acute pain related to surgery
Ans. (c) Risk for aspiration related to general anesthesia
Explanation: In the recovery room nurse is receiving client immediately after surgery. In the immediate post-operative period, airway is the most important priority. So, option c is the correct
7. Nursing student was taking BP of a client admitted in general ward. Student selected large cuff for the client. What finding should be expected by the instructor?
a. Falsely high
b. Falsely low
c. Correct reading
d. It can be high or low
Ans. (b) Falsely low
Explanation: The width of the bladder of the blood pressure cuff should be approximately 40% of the circumference of the upper arm midway between the olecranon and the acromion. the size of the bladder of the cuff should encircle 80–100% of the circumference of the upper arm at the same position. If the cough is large, it will give falsely low reading and a small cough will give falsely high BP value.
Nursing Exam Preparation MCQ 2024
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