NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:
Correct Answer: C
Rationale: This statement describes a normal assessment finding of the lower extremities. This assessment finding reflects problems caused by venous insufficiency. Decreased or absent pedal pulses reflect a problem caused by arterial insufficiency. The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation.
Question 2 of 5
When assessing the client's blood pressure, the nurse should use a cuff with a width that is __% of the circumference of the extremity. (Fill in the blank.)
Correct Answer: 40
Rationale: The blood pressure cuff width should be approximately 40% of the extremity’s circumference to ensure accurate readings. A cuff too narrow or wide can falsely elevate or lower readings.
Question 3 of 5
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
Correct Answer: A
Rationale: Tachycardia is a hallmark of hypovolemic shock, compensating for reduced blood volume. Hypothermia (
B) is secondary, bradypnea (
C) is atypical, and hypertension (
D) is not associated.
Question 4 of 5
A client being treated with sodium warfarin (Coumadin) has a prothrombin time of 120 seconds. The nurse recognizes that:
Correct Answer: A
Rationale: A prothrombin time of 120 seconds is excessively prolonged indicating a high bleeding risk. Close monitoring for bleeding (e.g. bruising hematuria) is critical. The dosage is not inadequate vitamin K restriction is routine and doubling doses is dangerous.
Question 5 of 5
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
Correct Answer: A
Rationale: Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake. This goal is not specific enough or related to the loss of appetite. This goal is not possible at this time based on his illness. This goal is helpful, but alone will not address his loss of appetite.