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
The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.
Question 3 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 4 of 5
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
Question 5 of 5
A client with a history of a peptic ulcer is being discharged. The nurse should teach the client to:
Correct Answer: A
Rationale: Spicy foods can irritate a peptic ulcer, delaying healing. Small meals, avoiding lying down post-meals, and limiting caffeine are also recommended.