NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?
Correct Answer: A
Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.
Question 2 of 5
The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
Correct Answer: D
Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.
Question 3 of 5
The nurse is assessing the client’s bowel sounds. Which finding indicates normal bowel sounds?
Correct Answer: C
Rationale: Normal bowel sounds are described as 'normal,' occurring every 5–20 seconds with a gurgling quality. Stronger than normal or hyperactive sounds suggest increased motility (e.g., diarrhea), while hypoactive sounds indicate reduced motility (e.g., ileus).
Question 4 of 5
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
Correct Answer: A
Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
Question 5 of 5
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:
Correct Answer: B
Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.