NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.
Question 2 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
Question 3 of 5
The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:
Correct Answer: C
Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.
Question 4 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 5 of 5
A common complaint of the client with an abdominal aortic aneurysm is:
Correct Answer: D
Rationale: A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.