NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?
Correct Answer: D
Rationale: Papilledema (optic disc swelling) is a specific sign of increased ICP due to pressure on the optic nerve. Vomiting (
A), headache (
B), and dizziness (
C) are less specific and occur in other conditions.
Question 2 of 5
A client with a history of sarcoidosis is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Sarcoidosis can cause lung granulomas, leading to dyspnea, so monitoring respiratory status is critical to assess lung function.
Question 3 of 5
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
Correct Answer: D
Rationale: Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension. Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
Question 4 of 5
A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck.
Correct Answer: A
Rationale: A complete blood count (CB
C) detects abnormal white blood cell counts, supporting a leukemia diagnosis. Chest x-ray (
B), bone marrow aspiration (
C), and CT scan (
D) are confirmatory but not initial tests.
Question 5 of 5
The nurse is assessing the vital signs of a client with pancreatic cancer. In addition to routine vital signs, the nurse assesses the fifth vital sign of:
Correct Answer: B
Rationale: Pain is considered the fifth vital sign, alongside temperature, pulse, respiration, and blood pressure. It is routinely assessed, especially in conditions like pancreatic cancer, which often causes significant pain due to tumor invasion or obstruction.