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 4 days postpartum client who is gravida 3, para 3, is examined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
Correct Answer: C
Rationale: Lochia rubra is bloody with clots and occurs 1-3 days postpartum. There is no such term as lochia rosa. Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
Question 3 of 5
The nurse is discharging a client with a prescription of eyedrops.
Correct Answer: B
Rationale: Administering a second eyedrop immediately (
B) prevents absorption of the first, indicating a need for teaching (wait 5–10 minutes). Shaking (
A), hand washing (
C), and proper instillation (
D) are correct.
Question 4 of 5
The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?
Correct Answer: C
Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.
Question 5 of 5
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
Correct Answer: D
Rationale: NG tube suction removes acids, leading to metabolic alkalosis, as indicated by the elevated pH (7.53).