NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

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NCLEX-RN Exam Practice Questions

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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

After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:

Correct Answer: C

Rationale: Infants delivered by cesarean section are at higher risk for respiratory distress syndrome because they do not experience chest compression in the birth canal, which helps expel lung fluid.

Question 3 of 5

When assessing the client's blood pressure, the nurse should use a cuff with a width that is __% of the circumference of the extremity. (Fill in the blank.)

Correct Answer: 40

Rationale: The blood pressure cuff width should be approximately 40% of the extremity’s circumference to ensure accurate readings. A cuff too narrow or wide can falsely elevate or lower readings.

Question 4 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.

Question 5 of 5

Which of the following factors affects the accuracy of pulse oximetry readings?

Question Image

Correct Answer: A, B, C

Rationale: Pulse oximetry accuracy is reduced by poor circulation (
A), improper probe placement (
B), and bright lighting (
C). Dark skin (
D) has minimal impact with modern sensors.

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