NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.
Question 2 of 5
Which of the following signs and symptoms experienced by a child with suspected appendicitis should the nurse correctly judge to be unrelated to the transient sympathetic effects caused by the acute abdominal pain?
Correct Answer: B
Rationale: Chills are not typically a sympathetic response to pain (unlike tachycardia, rapid breathing, or dilated pupils) and may indicate an infection or other complication.
Question 3 of 5
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
Question 4 of 5
A nurse is caring for a client with a new colostomy. Which of the following actions should the nurse include in the teaching plan to prevent skin breakdown around the stoma?
Correct Answer: A
Rationale: A skin barrier protects the peristomal skin from irritation caused by stool. Soap can irritate the skin, leaving the pouch off risks exposure, and petroleum jelly is not recommended.
Question 5 of 5
A client with a diagnosis of systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine (Plaquenil). The nurse should monitor the client for which of the following side effects?
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams to monitor for vision changes.