NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
Question 2 of 5
At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
Correct Answer: A
Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.
Question 3 of 5
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.
Question 4 of 5
A client with a history of atrial fibrillation is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in atrial fibrillation may indicate reduced cardiac output, so monitoring heart rate is the priority.
Question 5 of 5
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
Correct Answer: B
Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.