NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
Correct Answer: A
Rationale: Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. The limb has been immobilized already by the cast, and therefore immobilization is not a concern. Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.
Question 2 of 5
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
Correct Answer: C
Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).
Question 3 of 5
Which of the following is a classic manifestation of glomerulonephritis?
Correct Answer: A
Rationale: Hypertension is a classic manifestation of glomerulonephritis due to fluid retention and renal dysfunction. Lassitude and fatigue may occur but are less specific and vomiting/diarrhea are not typical.
Question 4 of 5
A client is 6 weeks pregnant. During her first prenatal visit, she asks, 'How much alcohol is safe to drink during pregnancy?' The nurse's response is:
Correct Answer: D
Rationale: No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. The recommended safe dosage of alcohol consumption during pregnancy is none.
Question 5 of 5
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.