NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
Correct Answer: A
Rationale: Sock and mitten burns (circumferential burns on hands and feet) are suggestive of immersion in hot water, inconsistent with a simple fall, raising suspicion of abuse.
Question 2 of 5
The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?
Correct Answer: D
Rationale: Papilledema (optic disc swelling) is a specific sign of increased ICP due to pressure on the optic nerve. Vomiting (
A), headache (
B), and dizziness (
C) are less specific and occur in other conditions.
Question 3 of 5
When the nurse checks the fundus of a client on the first postpartum day,she notes that the fundus is firm level with the umbilicus and displaced to the side. The next action the nurse should take is to:
Correct Answer: A
Rationale: A displaced fundus on the first postpartum day is often due to bladder distention which pushes the uterus aside. Checking for bladder distention (e.g. by palpation or encouraging voiding) is the next step to correct the displacement.
Question 4 of 5
A client with type 2 diabetes is prescribed metformin (Glucophage). Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Stopping metformin abruptly (
C) can worsen glycemic control, indicating a need for further teaching. Taking with meals (
A), monitoring sugar (
B), and reporting muscle pain (
D) are correct.
Question 5 of 5
A client with a history of a kidney transplant is receiving Prednisone. The nurse should monitor the client for:
Correct Answer: A
Rationale: Prednisone, a corticosteroid, suppresses immunity, increasing infection risk. Hypotension, hyperkalemia, and weight loss are not primary concerns; weight gain is more common.