NCLEX-RN
Free NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
Question 2 of 5
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
Question 3 of 5
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
Correct Answer: A
Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.
Question 4 of 5
A primigravida with(choices truncated due to document error; assuming standard options for context) diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?
Correct Answer: B
Rationale: Brethine (terbutaline) is a tocolytic that can exacerbate maternal diabetes by causing hyperglycemia, so this order should be questioned in a diabetic primigravida.
Question 5 of 5
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
Correct Answer: D
Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.