NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.
Question 2 of 5
The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
Correct Answer: D
Rationale: Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
Question 3 of 5
A client with a history of lymphoma is admitted with complaints of night sweats. The nurse should expect the client to have:
Correct Answer: A
Rationale: Night sweats are a B symptom of lymphoma, along with fever and weight loss, indicating systemic disease.
Question 4 of 5
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
Correct Answer: B
Rationale: It is necessary to keep the pin site clean and free from infection, which is critical in skeletal traction care.
Question 5 of 5
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.