NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
Correct Answer: D
Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.
Question 2 of 5
The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:
Correct Answer: D
Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.
Question 3 of 5
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
Question 4 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
Question 5 of 5
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
Correct Answer: D
Rationale: Contractions five minutes apart lasting 30-60 seconds indicate the onset of active labor. Two-minute contractions suggest advanced labor and back pain or urination are less specific signs.