NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.
Question 2 of 5
A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?
Correct Answer: B
Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.
Question 3 of 5
A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light-headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to:
Correct Answer: D
Rationale: This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. This would not be the first intervention the RN should initiate. The RN should understand the supine position and its effect on the gravid uterus and vena cava. The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
Question 4 of 5
The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
Question 5 of 5
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
Correct Answer: D
Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.