NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected pulmonary edema. Which finding is most expected?
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in pulmonary edema. Tachycardia, productive cough, and hypertension are more common than bradycardia, dry cough, or hypotension.
Question 2 of 5
The nurse is caring for a client with a history of multiple sclerosis. Which intervention is most appropriate to prevent complications?
Correct Answer: C
Rationale: Hot baths can exacerbate multiple sclerosis symptoms by increasing body temperature, causing fatigue or weakness. Weight-bearing exercise is encouraged, antibiotics are not routine, and fluid restriction is harmful.
Question 3 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 4 of 5
The nurse is caring for a client with a history of a hip fracture who is in Buck’s traction. The nurse should:
Correct Answer: C
Rationale: In Buck’s traction, weights must hang freely off the floor to maintain proper traction force. Turning is limited, traction is not removed, and lotion is unnecessary.
Question 5 of 5
One of the most important criteria for the diagnosis of physical abuse is inconsistency between the appearance of the injury and the history of how the injury occurred. Which one of the following situations should alert the nurse to the possibility of abuse?
Correct Answer: A
Rationale: Sock and mitten burns (circumferential burns on hands and feet) are suggestive of immersion in hot water, inconsistent with a simple fall, raising suspicion of abuse.