NCLEX-RN Practice Questions with Nurse Brennan
Question 1: A 6-month-old infant is admitted to the pediatric unit with a diagnosis of bronchiolitis caused by Respiratory Syncytial Virus (RSV). Which nursing action is the priority?
A. Administering antibiotics
B. Administering humidified oxygen
C. Starting an intravenous line
D. Teaching the parents about the disease
Correct Answer: B. Administering humidified oxygen
Rationale: Providing humidified oxygen is crucial for infants with bronchiolitis caused by RSV as it helps maintain adequate oxygen saturation levels. The infant may experience difficulty breathing due to the virus; therefore, ensuring adequate oxygenation is a top priority. Antibiotics are not effective against viruses, starting an IV line may be necessary but is not the first priority, and teaching is important but must wait until immediate needs are addressed.
Question 2: A nurse is caring for an adult patient who has just returned from abdominal surgery. What is the most effective way to prevent respiratory complications?
A. Keeping the patient on bed rest
B. Monitoring the patient's vital signs
C. Encouraging deep breathing and coughing exercises
D. Administering pain medication regularly
Correct Answer: C. Encouraging deep breathing and coughing exercises
Rationale: Deep breathing and coughing exercises help expand the lungs, clear secretions, and prevent atelectasis (collapse of the lung), particularly important in postoperative patients. While monitoring vital signs and administering pain medication are also essential components of care, encouraging respiratory exercises directly helps prevent respiratory complications.
Question 3: A patient is admitted with diabetic ketoacidosis (DKA). Which clinical manifestation should the nurse expect to assess in this patient?
A. Shallow, slow respirations
B. Cold, clammy skin
C. Blood glucose level below 70 mg/dL
D. Fruity-scented breath
Correct Answer: D. Fruity-scented breath
Rationale: A fruity odor on the breath is associated with the presence of acetone, a byproduct of the ketones produced when fat is metabolized for energy in DKA. Shallow, slow respirations describe a different pattern than the deep, rapid breathing (Kussmaul respirations) often seen in DKA. Cold, clammy skin and low blood glucose levels are more typical of hypoglycemia, not DKA.
Question 4: A nurse is providing education to a client with chronic obstructive pulmonary disease (COPD) about using a metered-dose inhaler (MDI). Which statement by the client indicates a need for further teaching?
A. "I will shake the inhaler well before use."
B. "I will breathe in rapidly while pressing down the inhaler."
C. "I should hold my breath for about 10 seconds after inhaling."
D. "I need to rinse my mouth after using a corticosteroid inhaler."
Correct Answer: B. "I will breathe in rapidly while pressing down the inhaler."
Rationale: The correct method for using an MDI involves breathing in slowly and deeply while pressing down on the inhaler, not rapidly. This ensures that the medication is delivered properly to the airways. All other statements are correct.
Question 5: A 4-year-old child is admitted to the emergency department with suspected epiglottitis. Which of the following interventions should the nurse perform first?
A. Prepare for intubation
B. Obtain a throat culture
C. Encourage oral fluids
D. Provide a distraction with toys
Correct Answer: A. Prepare for intubation
Rationale: Epiglottitis is a medical emergency due to the risk of airway obstruction. The priority is to maintain a patent airway, which may require intubation. Throat cultures and encouraging fluids could exacerbate the airway issue and worsen the condition.
Question 6: A patient with type 1 diabetes mellitus has an order for an insulin sliding scale. The nurse should check the patient’s blood glucose level at which time to determine the need for insulin?
A. Before meals and at bedtime
B. Only in the morning
C. Every 60 minutes
D. Once a day at noon
Correct Answer: A. Before meals and at bedtime
Rationale: Sliding scale insulin is commonly administered based on blood glucose readings taken before meals and at bedtime. This ensures proper management of blood glucose levels throughout the day, adjusting as necessary with the carbohydrate intake and fasting overnight levels.
