NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (
A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (
B) can worsen tissue damage. Changing pads (
C) prevents irritation but doesn’t directly improve perfusion.
Question 2 of 5
A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
Correct Answer: D
Rationale: Low pH, high PCO2, and normal HCO3 indicate uncompensated respiratory acidosis, reflecting acute exacerbation of COPD.
Question 3 of 5
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
Correct Answer: D
Rationale: When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.
Question 4 of 5
The client is prescribed warfarin (Coumadin). Which food should the nurse instruct the client to limit?
Correct Answer: A
Rationale: Spinach is high in vitamin K, which antagonizes warfarin’s anticoagulant effect, potentially reducing its efficacy. Apples, chicken, and rice have negligible vitamin K.
Question 5 of 5
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.