NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing a client who has a sacral pressure ulcer. The wound has partial thickness, loss of dermis, and a red-pink wound bed. No slough is present. How would the nurse chart this wound?
Correct Answer: B
Rationale: A partial-thickness ulcer with loss of dermis and a red-pink bed is Stage II. Stage I is non-blanchable redness, Stage III involves full-thickness loss, and Stage IV exposes muscle or bone.
Question 2 of 5
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
Correct Answer: C
Rationale: Pain during CPM use may indicate improper settings or complications, requiring physician notification.
Question 3 of 5
A client complains of sharp, stabbing pain in the right lower quadrant that is graded as level 8 on a scale of 10. The nurse knows that pain of this severity can best be managed using:
Correct Answer: D
Rationale: Morphine sulfate is the most effective for severe, acute pain due to its strong opioid properties.
Question 4 of 5
An ICU nurse is caring for a client receiving total parenteral nutrition (TPN) via IV. The client's infusion ended 2 hours ago and the pharmacy has not yet sent another bag. The client is diaphoretic, tachycardic, and states he feels weak, dizzy, and fatigued. The nurse suspects
Correct Answer: D
Rationale: Abrupt cessation of TPN can cause hypoglycemia due to persistent insulin secretion, leading to diaphoresis, tachycardia, weakness, and dizziness.
Question 5 of 5
A nurse is planning care for a client with human immunodeficiency virus. The nurse knows to wear gloves under the following circumstance(s). Select all that apply.
Correct Answer: A, C, D
Rationale: Gloves are required for contact with open wounds, starting an IV, or drawing blood due to potential exposure to blood or body fluids, per standard precautions. Gloves are not needed for all contact.