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 registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
Question 3 of 5
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
Question 4 of 5
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
Question 5 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.