NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
Question 2 of 5
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
Correct Answer: C
Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.
Question 3 of 5
The nurse is caring for a client with a history of myasthenia gravis. The nurse should assess the client for:
Correct Answer: A
Rationale: Myasthenia gravis causes autoimmune destruction of acetylcholine receptors, leading to muscle weakness, especially in the eyes, face, and limbs, a key assessment finding.
Question 4 of 5
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
Question 5 of 5
A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:
Correct Answer: B
Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.