NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
Correct Answer: C
Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.
Question 2 of 5
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
Correct Answer: A
Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.
Question 3 of 5
The nurse is assessing an adult female client for hypovolemia.
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (
B) and BUN (
D) are within normal ranges, and urine specific gravity (
C) is normal, not elevated as expected in hypovolemia.
Question 4 of 5
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
Correct Answer: D
Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
Question 5 of 5
Which situation would be reportable to the state board of nursing?
Correct Answer: B
Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.