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 pelvic skin traction for low back pain is at risk of which of the following problems associated with decreased mobility? Select all that apply.
Correct Answer: A,B,C
Rationale: Decreased mobility from traction increases risks of orthostatic hypotension (
A), muscle weakness (
B), and venous stasis (
C). Dysuria (
D) and confusion (E) are less directly related.
Question 3 of 5
A client has accidentally splashed a toxic (although not caustic) substance in his right eye and the nurse must flush the eye. Which of the following steps are correct? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Correct eye irrigation includes syringe 0.5 inch above eye (
B), flushing 5 minutes (
C), holding eyelid open (
D), and using a basin (E). Head down (
A) is incorrect; tilt toward affected side.
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
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
Correct Answer: A
Rationale: A fundus displaced to the right on the first postpartum day is often due to bladder distention, which should be assessed next.