NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The client who is 2 weeks post-burn with a 40% deep partial-thickness injury still has open wounds. The nurse's assessment reveals the following findings: temperature 96.5°F, BP 87/40, and severe diarrhea stools. What problem does the nurse most likely suspect?
Correct Answer: C
Rationale: Hypothermia, hypotension, and diarrhea suggest systemic gram-negative infection, likely sepsis, due to bacterial translocation from open wounds or the gut in a burn patient.
Question 2 of 5
A nurse is working with an immobile client and doing passive range-of-motion (ROM) exercises on his legs. The client states the exercise is too painful and does not want to continue. The nurse should
Correct Answer: D
Rationale: Pain during ROM exercises may indicate injury. Stopping the exercise prevents harm, with further assessment or pain management to follow.
Question 3 of 5
A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?
Correct Answer: A
Rationale: Low back pain is a hallmark of acute hemolytic transfusion reaction due to hemolysis and kidney involvement. Fever, urticaria, or neck vein distention suggest other complications.
Question 4 of 5
A client with heart failure has been prescribed the DASH diet (dietary approaches to stop hypertension) and must limit sodium intake to 2300 mg per day. Which of the following statements by the client indicates a need for further education?
Correct Answer: A
Rationale: Stopping added salt (
A) is insufficient; the DASH diet requires limiting processed foods and monitoring total sodium. Dairy (
B), vegetables/fruits (
C), and meat limits (
D) are correct.
Question 5 of 5
An elderly client with glaucoma has been prescribed Timoptic eyedrops. Timoptic should be used with caution in clients with a history of:
Correct Answer: C
Rationale: Timoptic (timolol), a beta-blocker, should be used cautiously in clients with emphysema, as it can exacerbate respiratory conditions.