NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
Question 2 of 5
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
Question 3 of 5
The nurse is caring for a client with a history of a hiatal hernia who is receiving Propulsid (cisapride). The nurse should monitor the client for:
Correct Answer: A
Rationale: Cisapride can prolong the QT interval, risking arrhythmias, requiring cardiac monitoring. Hypotension, constipation, and weight gain are not primary side effects.
Question 4 of 5
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.
Question 5 of 5
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.