NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 of 5
A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
Correct Answer: D
Rationale: Trendelenburg sign is associated with congenital hip dysplasia, where the pelvis tilts downward on the unaffected side when the child stands on the affected leg, indicating hip instability.
Question 2 of 5
A client being treated with sodium warfarin has an INR of 8.0. Which intervention would be most important to include in the nursing care plan?
Correct Answer: A
Rationale: An INR of 8.0 indicates a high risk of bleeding, so assessing for abnormal bleeding is the priority intervention.
Question 3 of 5
A tornado warning has been issued in the area surrounding the hospital. Which action by the nurse is most appropriate to ensure client safety?
Correct Answer: B
Rationale: Moving clients to the hallway, closing blinds, and shutting doors minimizes risks from flying debris and broken windows during a tornado.
Question 4 of 5
A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, 'I don't know why you are all so worried; I am in control. I don't have a problem.' Which defense mechanism is being utilized?
Correct Answer: D
Rationale: Denial is the defense mechanism where the client refuses to acknowledge the reality of their substance abuse problem, minimizing its severity.
Question 5 of 5
The physician is preparing to remove a central line. The nurse should tell the client to:
Correct Answer: C
Rationale: Holding the breath during central line removal prevents air from being drawn into the vein, reducing the risk of air embolus.