NCLEX-RN
NCLEX RN Practice Exam Questions
Extract:
Question 1 of 5
A pediatric nurse would be concerned by which of the following sets of vital signs?
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
Question 2 of 5
The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to:
Correct Answer: B
Rationale: Holding breath and bearing down (Valsalva maneuver) prevents air entry into the pleural space during chest tube removal.
Question 3 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 4 of 5
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
Question 5 of 5
A nurse is assessing a 33-year-old patient who underwent a cholecystectomy 18 hours prior. The nurse notes 500 mL of greenish-brown fluid has drained from the T-tube postoperatively. The nurse should
Correct Answer: A
Rationale: Greenish-brown drainage (bile) from a T-tube post-cholecystectomy is expected (up to 500-1000 mL/day initially). The nurse should document and monitor, not assume infection or intervene unnecessarily.