NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?
Correct Answer: D
Rationale: may be confused and stuporous
Question 2 of 5
A client has accidentally splashed a toxic (although not caustic) substance in his right eye and the nurse must flush the eye. Which of the following steps are correct? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Correct eye irrigation includes syringe 0.5 inch above eye (
B), flushing 5 minutes (
C), holding eyelid open (
D), and using a basin (E). Head down (
A) is incorrect; tilt toward affected side.
Question 3 of 5
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care is essential to prevent infection at the site of cervical tongs, while altering traction or bed position could compromise spinal alignment.
Question 4 of 5
The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
Correct Answer: C
Rationale: A heart rate of 60 bpm in a 6-month-old is too low (normal is 80-160 bpm), indicating possible digitalis toxicity, which should be reported.
Question 5 of 5
The nurse is assessing a client who has a sacral pressure ulcer. The wound has partial thickness, loss of dermis, and a red-pink wound bed. No slough is present. How would the nurse chart this wound?
Correct Answer: B
Rationale: A partial-thickness ulcer with loss of dermis and a red-pink bed is Stage II. Stage I is non-blanchable redness, Stage III involves full-thickness loss, and Stage IV exposes muscle or bone.