NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
Correct Answer: D
Rationale: basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates
Question 2 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 3 of 5
The nurse is precepting a student nurse on the medical-surgical unit. The student nurse is preparing to administer insulin. Which action by the student nurse calls for immediate intervention?
Correct Answer: B
Rationale: Regular insulin is the only type safe for IV administration; other insulins like NPH are not, requiring immediate intervention.
Question 4 of 5
Where is the best site for examining for the presence of petechiae in an African American client?
Correct Answer: C
Rationale: The earlobes are a reliable site to assess petechiae in dark-skinned individuals, as they are less pigmented and allow easier visualization of small hemorrhages.
Question 5 of 5
While performing a neurological assessment on a client with a closed head injury, the nurse notes a positive Babinski reflex. The nurse should:
Correct Answer: D
Rationale: A positive Babinski reflex in an adult with a head injury suggests neurological damage, warranting immediate physician notification.