NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 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 2 of 5
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
Correct Answer: B
Rationale: The Whipple procedure is typically performed for pancreatic cancer in the head of the pancreas, involving resection of the pancreatic head, duodenum, and other structures.
Question 3 of 5
A client arrives from surgery following an abdominal perineal resection with a permanent ileostomy. What should be the priority nursing care during the post-op period?
Correct Answer: D
Rationale: Facilitating perineal wound drainage is the priority to prevent infection and promote healing in the immediate postoperative period, as the perineal wound is at high risk for complications.
Question 4 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 5 of 5
When applying the leads for a 12-lead electrocardiogram, the nurse places V1 and V2 at the fourth intercostal space to the right and left of the sternum. Which of the remaining leads is placed at the fifth intercostal space on the left midclavicular line?
Correct Answer: B
Rationale: Lead V4 (
B) is placed at the fifth intercostal space on the left midclavicular line in a 12-lead ECG.