NCLEX-RN
NCLEX-RN Exam Practice 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 prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.
Question 2 of 5
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
Correct Answer: C
Rationale: A deficit in sodium concentration results in muscular weakness and lethargy. Muscle fatigue and hypotonia are caused by hypercalcemia. Muscle weakness and fatigue are classic signs of hypokalemia. Hypermagnesemia can cause muscle weakness, paralysis, and coma.
Question 3 of 5
The nurse is caring for a client with a history of a pneumothorax who has a chest tube. The nurse should:
Correct Answer: D
Rationale: Subcutaneous emphysema (air under the skin) indicates chest tube malfunction or air leak, requiring monitoring. Clamping, raising the system, and stripping are contraindicated.
Question 4 of 5
The nurse is caring for a client with a history of a ventricular septal defect. Which finding should be reported to the doctor immediately?
Correct Answer: D
Rationale: Cyanosis in a ventricular septal defect indicates significant shunting and hypoxemia, a critical finding requiring immediate reporting. Murmurs, tachycardia, and fatigue are expected but less urgent.
Question 5 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Gestational trophoblastic disease (e.g. molar pregnancy) causes markedly elevated hCG levels due to abnormal trophoblastic proliferation. Fetal heart tones are absent uterine size is larger and hypotension is not typical.