NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.
Question 2 of 5
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
Question 3 of 5
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
Correct Answer: D
Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
Question 4 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 5 of 5
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
Correct Answer: A
Rationale: Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. The limb has been immobilized already by the cast, and therefore immobilization is not a concern. Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.