NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
Question 2 of 5
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
Correct Answer: B
Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.
Question 3 of 5
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
Correct Answer: C
Rationale: Vinaigrette may contain alcohol, which reacts with disulfiram, causing severe symptoms.
Question 4 of 5
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
Correct Answer: A
Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.
Question 5 of 5
A 54-year-old female is brought into the ED by her spouse. The client's spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
Correct Answer: A
Rationale: Hypocalcemia (calcium 7.2 mg/dL, normal 8.5–10.2) can cause muscle stiffness and anxiety, requiring immediate notification. Other results are normal.