NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care is essential to prevent infection at the site of cervical tongs, while altering traction or bed position could compromise spinal alignment.
Question 2 of 5
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help with decreasing the client's confusion by:
Correct Answer: D
Rationale: A nightlight reduces disorientation and confusion in elderly clients by providing visual cues in the dark.
Question 3 of 5
Which of the following tasks would an RN NOT delegate to an LPN?
Correct Answer: B
Rationale: Assessment, such as evaluating ambulation ability, is outside the LPN’s scope and reserved for RNs. The other tasks are within the LPN’s scope of practice.
Question 4 of 5
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
Correct Answer: B
Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.
Question 5 of 5
The nurse is assessing a client who has a sacral pressure ulcer. The wound has partial thickness, loss of dermis, and a red-pink wound bed. No slough is present. How would the nurse chart this wound?
Correct Answer: B
Rationale: A partial-thickness ulcer with loss of dermis and a red-pink bed is Stage II. Stage I is non-blanchable redness, Stage III involves full-thickness loss, and Stage IV exposes muscle or bone.