NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected meningitis. Which finding is most concerning?
Correct Answer: A
Rationale: Neck stiffness (nuchal rigidity) is a hallmark sign of meningitis, indicating meningeal irritation and requiring urgent evaluation. Fever, photophobia, and headache are common but less specific without neck stiffness.
Question 2 of 5
A 4 days postpartum client who is gravida 3, para 3, is examined by the home health nurse during her first postpartum home visit. The nurse notes that she has a pink vaginal discharge with a serosanguineous consistency. The nurse would most accurately chart the client's lochia as:
Correct Answer: C
Rationale: Lochia rubra is bloody with clots and occurs 1-3 days postpartum. There is no such term as lochia rosa. Lochia serosa is a pink-brown discharge with a serosanguineous consistency that occurs 4-9 days postpartum. Lochia alba is yellow to white in color and occurs approximately 10 days postpartum.
Question 3 of 5
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.
Question 4 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 5 of 5
A client is admitted to the postpartal unit with a large amount of lochia rubra, uterine enlargement, and excessive clots. Which medication will likely be ordered for the client?
Correct Answer: D
Rationale: Hemabate, a prostaglandin, is used to treat postpartum hemorrhage by promoting uterine contractions to control bleeding. Fentanyl and Stadol are analgesics, and Prepidil is for labor induction, not hemorrhage.