NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
The client has surgery for removal of a prolactinoma. Which of the following interventions would be appropriate for this client?
Correct Answer: C
Rationale: After prolactinoma surgery (transsphenoidal hypophysectomy) elevating the head of the bed 30° reduces intracranial pressure and prevents cerebrospinal fluid leakage. Trendelenburg position coughing and nose blowing may increase pressure or disrupt the surgical site.
Question 2 of 5
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.
Question 3 of 5
A female client comes for her second prenatal visit. The nurse-midwife tells her, 'Your blood tests reveal that you do not show immunity to the German measles.' Which notation will the nurse include in her plan of care for the client? 'Will need . . .
Correct Answer: D
Rationale: Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. The rubella vaccine is not given during pregnancy because of its teratogenicity. Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
Question 4 of 5
A client with a history of a deep vein thrombosis is receiving Warfarin (Coumadin). The nurse should teach the client to avoid:
Correct Answer: A
Rationale: Green leafy vegetables are high in vitamin K, which antagonizes warfarin’s anticoagulant effect. Dairy, citrus, and high-fat foods do not significantly affect warfarin.
Question 5 of 5
The client is admitted with a diagnosis of acute pancreatitis. Which position is most comfortable for the client?
Correct Answer: D
Rationale: Side-lying with knees flexed reduces pressure on the inflamed pancreas, providing comfort in acute pancreatitis. Supine, prone, and Fowler’s positions may increase discomfort.