NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client being treated with sodium warfarin (Coumadin) has a prothrombin time of 120 seconds. The nurse recognizes that:
Correct Answer: A
Rationale: A prothrombin time of 120 seconds is excessively prolonged indicating a high bleeding risk. Close monitoring for bleeding (e.g. bruising hematuria) is critical. The dosage is not inadequate vitamin K restriction is routine and doubling doses is dangerous.
Question 2 of 5
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
Correct Answer: A
Rationale: Abdominal assessment follows the sequence: inspection, auscultation, palpation. Auscultation is done before palpation to avoid altering bowel sounds. Inspection identifies visible abnormalities first.
Question 3 of 5
The nurse is assessing a client with suspected hypoglycemia. Which finding is most consistent with this condition?
Correct Answer: A
Rationale: Hypoglycemia causes sympathetic activation, leading to tremors and sweating as the body attempts to raise glucose levels. Chest pain, fever, and bradycardia are not typical.
Question 4 of 5
The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?
Correct Answer: D
Rationale: Papilledema (optic disc swelling) is a specific sign of increased ICP due to pressure on the optic nerve. Vomiting (
A), headache (
B), and dizziness (
C) are less specific and occur in other conditions.
Question 5 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.