NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client with a C-34 fracture has just arrived in the emergency room. The primary nursing intervention is:
Correct Answer: B
Rationale: If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. Primary intervention is protection of the airway and adequate ventilation. All other interventions are secondary to adequate ventilation.
Question 2 of 5
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:
Correct Answer: B
Rationale: Discomfort with ankle dorsiflexion is not expected with meningitis. Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. Discomfort with wrist flexion is not expected with meningitis. Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
Question 3 of 5
A client has sustained a severe head injury and damaged the preoccipital lobe. The nurse should remain particularly alert for which of the following problems?
Correct Answer: A
Rationale: The preoccipital (occipital) lobe processes vision. Damage causes visual impairment (e.g., cortical blindness). Swallowing (
B) involves the brainstem, judgment (
C) the frontal lobe, and hearing (
D) the temporal lobe.
Question 4 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.
Question 5 of 5
A client with a history of gout is prescribed allopurinol (Zyloprim). Which laboratory value should the nurse monitor closely?
Correct Answer: A
Rationale: Allopurinol reduces uric acid production in gout. Monitoring serum uric acid ensures therapeutic effect. Glucose (
B), potassium (
C), and hemoglobin (
D) are not directly affected.