NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
Correct Answer: B
Rationale: Fetal heart tones are a definitive, objective sign of pregnancy, detectable around 20 weeks.
Question 2 of 5
The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
Correct Answer: D
Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.
Question 3 of 5
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
Correct Answer: C
Rationale: Pain during CPM use may indicate improper settings or complications, requiring physician notification.
Question 4 of 5
An ICU nurse is caring for a client receiving total parenteral nutrition (TPN) via IV. The client's infusion ended 2 hours ago and the pharmacy has not yet sent another bag. The client is diaphoretic, tachycardic, and states he feels weak, dizzy, and fatigued. The nurse suspects
Correct Answer: D
Rationale: Abrupt cessation of TPN can cause hypoglycemia due to persistent insulin secretion, leading to diaphoresis, tachycardia, weakness, and dizziness.
Question 5 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. Nausea, headache, and dizziness are less specific.