NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a "crackling" noise with palpation. The nurse should further assess the client for which of the following problems?
Correct Answer: B
Rationale: Puffy skin and crackling (crepitus) over the clavicle suggest subcutaneous emphysema, where air escapes into tissues, often with rib fractures. Flail chest (
A) involves paradoxical chest movement, infiltrated IV (
C) is unrelated, and pneumothorax (
D) causes absent breath sounds.
Question 2 of 5
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (
B), turning (
C), or supine positioning (
D) delays critical action.
Question 3 of 5
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
Question 4 of 5
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When assessing the client’s response to the Pitocin, the nurse should give priority to:
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, risking fetal distress. Checking the fetal heart rate is the priority to ensure fetal well-being. Blood pressure, contractions, and urinary output are monitored but are secondary to fetal status.
Question 5 of 5
A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:
Correct Answer: A
Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.