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
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
Correct Answer: B
Rationale: HIV is a contraindication for breastfeeding due to the risk of viral transmission to the infant. Diabetes hypertension and thyroid disease are not absolute contraindications though they require management.
Question 3 of 5
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?
Correct Answer: B
Rationale: Aspirin should not be given on an empty stomach because it is irritating to the mucosa. Bleeding from decreased clotting capacity may be caused by aspirin toxicity. A regular schedule of aspirin administration is important to maintain a satisfactory drug level in the body. Aspirin toxicity may affect cranial nerve VIII, leading to tinnitus (ringing in the ears).
Question 4 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 5 of 5
The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
Correct Answer: B
Rationale: Guillain-Barre syndrome is characterized by elevated protein levels in cerebrospinal fluid with a normal cell count, reflecting nerve root inflammation.