NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client's renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate?
Correct Answer: D
Rationale: A low-calcium and phosphorus diet will reduce further calculi formation.
Question 2 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 3 of 5
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
Correct Answer: C
Rationale: Nudity is not a trigger for reminding males to perform TSE. Testicles become more firm when exposed to cool temperatures, but not large and bulky. The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. The examination should not be painful.
Question 4 of 5
The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?
Correct Answer: D
Rationale: Papilledema (optic disc swelling) is a specific sign of increased ICP due to pressure on the optic nerve. Vomiting (
A), headache (
B), and dizziness (
C) are less specific and occur in other conditions.
Question 5 of 5
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level, drawn two hours ago, is 30 mcg/mL. What is the appropriate nursing action?
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is toxic (therapeutic range: 10–20 mcg/mL). Holding the dose and notifying the physician prevents toxicity. Administering (
A), decreasing (
C), or increasing (
D) the dose without physician input is unsafe.