NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
Question 2 of 5
Which finding is expected in the normal newborn?
Correct Answer: B
Rationale: The Moro reflex, a startle response to sudden movement, is a normal finding in newborns, present until about 3-6 months. Epstein pearls are benign but not universal, and the others are abnormal.
Question 3 of 5
Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?
Correct Answer: C
Rationale: Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. The side effects of morphine sulfate include respiratory depression. Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.
Question 4 of 5
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia requiring immediate oxygen administration (e.g. via mask) to restore oxygenation. Elevating the head rechecking later or assessing heart rate are secondary to correcting hypoxia.
Question 5 of 5
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (
A) is unreliable, stridor (
B) suggests obstruction, and carbonaceous particles (
D) indicate smoke inhalation.