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
A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:
Correct Answer: A
Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.
Question 3 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client’s heart rate is 58 beats per minute. What is the nurse’s best action?
Correct Answer: B
Rationale: A heart rate of 58 bpm is below the threshold (60 bpm) for digoxin administration, as it may worsen bradycardia. Holding the dose and notifying the physician (
B) is safest. Administering (
A), reducing (
C), or delaying (
D) is inappropriate.
Question 4 of 5
Hematotympanum and otorrhea are associated with which of the following head injuries?
Correct Answer: A
Rationale: Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms.
Question 5 of 5
The client is admitted with a diagnosis of hypovolemic shock. Which fluid is most appropriate for initial resuscitation?
Correct Answer: A
Rationale: 0.9% Normal saline is the preferred isotonic fluid for initial resuscitation in hypovolemic shock to restore intravascular volume. Dextrose is hypotonic, 3% saline is hypertonic, and lactated Ringer’s is used in specific cases like burns.