NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 2 of 5
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
Correct Answer: B
Rationale: Consistent limit setting will help the client to know what is acceptable behavior, addressing the disruptive actions effectively.
Question 3 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 4 of 5
The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?
Correct Answer: C
Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.
Question 5 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 prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.