NCLEX-RN
NCLEX RN Practice Exam Questions
Extract:
Question 1 of 5
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (
C) balance safety and practicality.
Question 2 of 5
The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
Correct Answer: A,C,D,E
Rationale:
Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
Question 3 of 5
The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?
Correct Answer: C
Rationale: in this level of anxiety, client is unable to process thoughts and feelings for problem solving
Question 4 of 5
The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that:
Correct Answer: B
Rationale: A glycosylated hemoglobin (HbA1c) of 2.5% is below the normal range (4-5.6%), indicating overly tight glucose control, but in context, it suggests good diabetes management.
Question 5 of 5
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.