NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A client with a history of breast cancer is admitted with complaints of lymphedema. The nurse should give priority to:
Correct Answer: A
Rationale: Compression therapy reduces swelling in lymphedema post-breast cancer, improving comfort and function.
Question 2 of 5
A child is admitted with severe headache, fever, vomiting, photophobia, drowsiness, and stiff neck associated with viral meningitis. She will be more comfortable if the nurse:
Correct Answer: A
Rationale: The discomfort of photophobia is alleviated by dimming the lights. Helping the child to breathe slowly and deeply may help to reduce anxiety, but it will not alleviate other discomforts of viral meningitis. It is important to maintain fluid balance, but sips of warm liquids do not alleviate the discomforts of meningitis. A large, soft pillow under her head causing neck flexion is likely to increase her discomfort owing to stretching of the meninges.
Question 3 of 5
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
Question 4 of 5
The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.
Question 5 of 5
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (
A) is unreliable, stridor (
B) suggests obstruction, and carbonaceous particles (
D) indicate smoke inhalation.