NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
An infant's Apgar score is 9 at 5 minutes. The most likely cause for the deduction of one point is:
Correct Answer: C
Rationale: Blue hands and feet (acrocyanosis) are common in newborns and likely cause a 1-point deduction in the appearance category of the Apgar score.
Question 2 of 5
The client is taking rifampin 600 mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?
Correct Answer: B
Rationale: Rifampin causes orange-red discoloration of urine, a normal side effect the nurse should explain.
Question 3 of 5
A nurse is planning care for a client with human immunodeficiency virus. The nurse knows to wear gloves under the following circumstance(s). Select all that apply.
Correct Answer: A, C, D
Rationale: Gloves are required for contact with open wounds, starting an IV, or drawing blood due to potential exposure to blood or body fluids, per standard precautions. Gloves are not needed for all contact.
Question 4 of 5
The nurse is assessing a client who has a sacral pressure ulcer. The wound has partial thickness, loss of dermis, and a red-pink wound bed. No slough is present. How would the nurse chart this wound?
Correct Answer: B
Rationale: A partial-thickness ulcer with loss of dermis and a red-pink bed is Stage II. Stage I is non-blanchable redness, Stage III involves full-thickness loss, and Stage IV exposes muscle or bone.
Question 5 of 5
What airborne precautions should the nurse anticipate when a client with measles is admitted to the hospital? Select all that apply.
Correct Answer: C,D
Rationale: Measles requires airborne precautions, including a negative pressure room (
C) and an N-95 respirator (
D). Surgical masks (
A) are insufficient, and dedicated entrances (E) are not standard. Client masking during transport (
B) is recommended but not always mandatory.