NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Correct Answer: D
Rationale: Diversion may help the child to focus on a pleasant activity instead of on his headache.
Question 2 of 5
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
Order the Items
Source Container
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.
Question 3 of 5
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
Question 4 of 5
The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
Question 5 of 5
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.