NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
Correct Answer: B
Rationale: It is necessary to keep the pin site clean and free from infection, which is critical in skeletal traction care.
Question 2 of 5
A post-operative client has an order for Demerol (meperidine) 75 mg and Phenergan (promethazine) 25 mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an:
Correct Answer: B
Rationale: Meperidine (opioid) and promethazine (antihistamine) together produce a synergistic effect, enhancing pain relief and sedation. Promethazine potentiates meperidine’s effects.
Question 3 of 5
When assessing the client with acute arterial occlusion, the nurse would expect to find:
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to tissue necrosis, which may present as minute blackened areas on the toes, indicating severe ischemia.
Question 4 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.
Question 5 of 5
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, 'It's not so easy for me to just go right to the hospital like that.' After acknowledging her feelings, which of these approaches by the nurse would probably be best?
Correct Answer: B
Rationale: This answer does not hold the client accountable for her own health. The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?