NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?
Correct Answer: A
Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.
Question 2 of 5
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
Question 3 of 5
A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.
Question 4 of 5
Which behaviors are expected to be observed in the 18-month old?
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (
B), point to body parts (
C), and kick balls (E). Vocabulary is ~20-50 words (
A), and questioning (
D) emerges later (~2-3 years).
Question 5 of 5
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
Correct Answer: D
Rationale: Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.