NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
Correct Answer: A
Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.
Question 2 of 5
The client with hyperemesis gravidarum is at risk for developing:
Correct Answer: B
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to dehydration and loss of stomach acid resulting in metabolic acidosis. The dehydration exacerbates the acid-base imbalance.
Question 3 of 5
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
Correct Answer: C
Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.
Question 4 of 5
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.
Question 5 of 5
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.