NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?
Correct Answer: B
Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.
Question 2 of 5
A client with burns is admitted and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours; the client's CVP reading is 14 cm/Hâ‚‚O. Which evaluation by the nurse would be most accurate?
Correct Answer: D
Rationale: A CVP of 14 cm/Hâ‚‚O (normal: 3-8 cm/Hâ‚‚O) indicates fluid volume excess, likely from aggressive resuscitation, requiring careful monitoring to prevent complications.
Question 3 of 5
A 28-year-old woman with Guillain-Barre syndrome has been intubated and is on mechanical ventilation due to ascending paralysis. She has become increasingly worried and upset as the day has gone on. What would be the best response by the nurse to help the woman cope?
Correct Answer: D
Rationale: Acknowledging the client’s worry, offering support, and encouraging family presence promote emotional coping and reduce isolation. Other responses dismiss the client’s feelings or limit support.
Question 4 of 5
After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?
Correct Answer: C
Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.
Question 5 of 5
A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. The nurse would determine that these clinical manifestations are indicative of:
Correct Answer: B
Rationale: Shortness of breath, pleuritic pain, and hemoptysis are classic signs of pulmonary embolus, a complication of immobility from a fracture. The other conditions have different presentations.