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
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
Correct Answer: A
Rationale: Undercooked hamburger is a common source of E. coli, particularly strains like O157:H7, which can contaminate ground beef.
Question 3 of 5
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
Correct Answer: B
Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.
Question 4 of 5
The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?
Correct Answer: B
Rationale: Elevating the head to 30 degrees reduces intracranial pressure in traumatic brain injury, addressing symptoms like nausea and restlessness.
Question 5 of 5
The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
Correct Answer: C
Rationale: A heart rate of 60 bpm in a 6-month-old is too low (normal is 80-160 bpm), indicating possible digitalis toxicity, which should be reported.