NCLEX-RN
NCLEX RN Practice Test Free Questions
Extract:
Question 1 of 5
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.
Question 2 of 5
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.
Correct Answer: B
Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.
Question 3 of 5
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
Correct Answer: B
Rationale: Frequent laxative use can lead to dehydration and electrolyte imbalances due to excessive fluid and electrolyte loss through diarrhea.
Question 4 of 5
A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?
Correct Answer: D
Rationale: Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) - ICP. Given MAP = 70 and ICP = 22, CPP = 70 - 22 = 48. Thus, the answer is 48.
Question 5 of 5
A home health nurse finds the client lying unconscious in the doorway of her bathroom. The nurse checks for responsiveness by gently shaking the client and calling her name. When it is determined that the client is nonresponsive, the nurse should:
Correct Answer: C
Rationale: Opening the airway is the first step in managing an unresponsive client to ensure adequate ventilation.