NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.
Question 2 of 5
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
Question 3 of 5
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
Correct Answer: D
Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
Question 4 of 5
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
Question 5 of 5
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.