NCLEX-RN
Free NCLEX RN 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: The 'puffy' area and 'crackling' noise (crepitus) with palpation are classic signs of subcutaneous emphysema, where air is trapped under the skin, often due to a pneumothorax or rib fractures allowing air to escape into subcutaneous tissue.
Question 2 of 5
The nurse on the inpatient memory care unit is caring for a client with Alzheimer's who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Notifying security with a description ensures a rapid, coordinated response to locate the client and ensure safety.
Question 3 of 5
The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?
Correct Answer: C
Rationale: Pain is a late symptom of oral cancer, often occurring as the disease progresses and affects surrounding tissues.
Question 4 of 5
A 57-year-old male with a history of vasculitis has purple discolorations on his legs, each approximately 0.3 cm to 1 cm in size. He asks the nurse what these discolorations are called, and the nurse correctly calls them
Correct Answer: B
Rationale: Purpura are purple discolorations 0.3-1 cm, often seen in vasculitis due to small vessel bleeding. Petechiae are smaller (<0.3 cm), and ecchymosis is larger (>1 cm).
Question 5 of 5
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
Correct Answer: A,C,D
Rationale: Alternatives (
A), reassessment every 2 hours (
C), and a written policy (
D) are required for restraints. Confused clients aren't always safer (
B), most restrictive (E) is incorrect, and an order is needed (F).