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
A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?
Correct Answer: A
Rationale: Administering eye drops 5 minutes apart prevents dilution and ensures each medication's efficacy.
Question 3 of 5
A triage nurse is reviewing messages from four clients. The nurse's priority is which client?
Correct Answer: B
Rationale: Jaw and back pain intensifying rapidly in a 42-year-old female suggests a possible myocardial infarction, a life-threatening emergency requiring immediate attention.
Question 4 of 5
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
Correct Answer: A
Rationale: A fundus displaced to the right on the first postpartum day is often due to bladder distention, which should be assessed next.
Question 5 of 5
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?
Correct Answer: B
Rationale: In Bryant's traction, the buttocks should be slightly elevated (15° off the bed) to ensure proper alignment.