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
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C,
D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.
Question 3 of 5
The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
Question 4 of 5
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (
A), indicating a need for further teaching. Upright positioning (
B), taking with water (
C), and avoiding food (
D) are correct.
Question 5 of 5
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:
Correct Answer: D
Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.