NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
Correct Answer: A
Rationale:
To elicit the biceps reflex the nurse places a thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer. The other methods describe techniques for eliciting different reflexes (e.g. triceps or patellar).
Question 2 of 5
A client has ataxia following a cerebral vascular accident. The nurse should:
Correct Answer: A
Rationale: Ataxia post-stroke causes unsteady gait, increasing fall risk. Supervising ambulation ensures safety. Intake/output, speech therapy, and writing aids are unrelated to ataxia.
Question 3 of 5
A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck.
Correct Answer: A
Rationale: A complete blood count (CB
C) detects abnormal white blood cell counts, supporting a leukemia diagnosis. Chest x-ray (
B), bone marrow aspiration (
C), and CT scan (
D) are confirmatory but not initial tests.
Question 4 of 5
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
Question 5 of 5
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high, indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the varices to rupture?
Correct Answer: A
Rationale: Lifting heavy objects will increase intrathoracic pressure, thus placing the client at risk for rupturing esophageal varices.