NCLEX Questions, NCLEX RN Practice Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Exam Questions

Extract:


Question 1 of 5

A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?

Correct Answer: C

Rationale: Assessing and repositioning the pulse oximeter (
C) checks for false readings first. Oxygen (
B), notifying physician (
A), or ABGs (
D) follow if needed.

Question 2 of 5

The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?

Correct Answer: E

Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.

Question 3 of 5

The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:

Correct Answer: A

Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.

Question 4 of 5

The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?

Correct Answer: D

Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.

Question 5 of 5

A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.

Correct Answer: C,D

Rationale: Elbow ROM includes supination/pronation (
C) and flexion/extension (
D). Abduction/adduction (
A), hyperextension (
B), and rotation (E) are not applicable to the elbow joint.

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