NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
Correct Answer: A
Rationale: Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. This action is of lesser importance at this time. Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. Once the victim enters the emergency room, it is important not to leave her alone.
Question 2 of 5
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.
Question 3 of 5
Which situation would be reportable to the state board of nursing?
Correct Answer: B
Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.
Question 4 of 5
The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below which of the following levels?
Correct Answer: D
Rationale: A mean arterial pressure (MAP) below 80 mmHg compromises renal perfusion, leading to glomerular filtration failure. Higher MAPs (A, B,
C) maintain adequate kidney function.
Question 5 of 5
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU. A low-phenylalanine diet, healthy snacks, and preventing mental retardation are correct understandings.