NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 2 of 5
The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
Question 3 of 5
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
Correct Answer: B
Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (
A) is for abdominal exams, High Fowler’s (
C) is for breathing, and lithotomy (
D) is for pelvic procedures.
Question 4 of 5
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
Question 5 of 5
The client is admitted with a diagnosis of preterm labor. Which fetal monitoring technique is most appropriate?
Correct Answer: C
Rationale: Preterm labor requires fetal monitoring to assess well-being. Non-stress tests evaluate fetal heart rate and biophysical profiles assess multiple parameters (e.g. movement amniotic fluid). Both are appropriate.