NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client is being evaluated for carpal tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
Correct Answer: B
Rationale: Tinel’s sign involves tapping the median nerve to elicit pain/tingling in carpal tunnel syndrome. Phalen’s maneuver (
A) involves wrist flexion, Kernig’s (
C) and Brudzinski’s (
D) are for meningitis.
Question 2 of 5
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
Question 3 of 5
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to:
Correct Answer: D
Rationale: This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. This would not be the first intervention the RN should initiate. The RN should understand the supine position and its effect on the gravid uterus and vena cava. The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
Question 4 of 5
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
Correct Answer: C
Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.
Question 5 of 5
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.