NCLEX Questions, NCLEX RN Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

A client has accidentally splashed a toxic (although not caustic) substance in his right eye and the nurse must flush the eye. Which of the following steps are correct? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Correct eye irrigation includes syringe 0.5 inch above eye (
B), flushing 5 minutes (
C), holding eyelid open (
D), and using a basin (E). Head down (
A) is incorrect; tilt toward affected side.

Question 2 of 5

A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?

Correct Answer: D

Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.

Question 3 of 5

A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?

Correct Answer: A

Rationale: Moving the client closer to the nursing station allows close monitoring without violating the client’s refusal of restraints, prioritizing safety and autonomy.

Question 4 of 5

The nurse recognizes all of the following as common physical characteristics of a child with Down syndrome EXCEPT

Correct Answer: D

Rationale: Down syndrome features include small, low-set ears, downward slanting eyes, and hyperflexibility. An enlarged tongue (macroglossia) is less common or not a hallmark feature.

Question 5 of 5

The home health nurse is scheduled to visit four clients. Which client should she visit first?

Correct Answer: A

Rationale: The AIDS client with fever and cough may have an acute infection like pneumonia, requiring urgent assessment.

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