NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
Question 2 of 5
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
Question 3 of 5
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
Question 4 of 5
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
Correct Answer: A
Rationale: Autonomic dysreflexia, a life-threatening exaggerated sympathetic response, can occur in spinal cord injuries above T6, causing severe hypertension.
Question 5 of 5
A client is being evaluated for carpal tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
Correct Answer: B
Rationale: Tinel’s sign involves tapping the median nerve to elicit pain/tingling in carpal tunnel syndrome. Phalen’s maneuver (
A) involves wrist flexion, Kernig’s (
C) and Brudzinski’s (
D) are for meningitis.