NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
The nurse is assessing the circulation of a patient in a long leg cast. Which of the following assessments indicate adequate circulation to the extremity?
Correct Answer: D
Rationale: Brisk capillary refill of less than three seconds indicates adequate blood flow to the extremity as it shows that blood is returning quickly to the capillaries after compression. While the other options (no pain toe movement and sensation) are positive signs they do not directly assess circulation as effectively as capillary refill.
Question 2 of 5
A 79-year-old client with Alzheimer's disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client's care:
Correct Answer: A
Rationale: Alzheimer's clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions.
Question 3 of 5
The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client. The nurse instructs the client that B6 is given because it:
Correct Answer: D
Rationale: Isoniazid leads to Vitamin B6 deficiency, which is manifested as peripheral neuropathy.
Question 4 of 5
The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia?
Correct Answer: D
Rationale: Lochia alba occurs approximately 10 days after birth and is yellow to white. A discharge is classified as light when less than a 4-inch stain exists. Lochia serosa is pink to brown and occurs 3-4 days after delivery. A stain is classified as heavy when a peripad is saturated in 1 hour. Lochia granulosa is not a proper classification. Lochia rubra is red, consisting mainly of blood, debris, and bacteria, and lasts from the time of delivery to 3-4 days afterward. A stain is classified as moderate when less than a 6-inch stain exists.
Question 5 of 5
A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
Correct Answer: B
Rationale: A nasogastric tube post-laryngectomy decompresses the stomach, preventing vomiting and aspiration, which could stress the surgical site. Swelling, contamination, and mucosa healing are secondary.