NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
Correct Answer: D
Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.
Question 2 of 5
After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:
Correct Answer: A
Rationale: Undercooked hamburger is a common source of E. coli, particularly strains like O157:H7, which can contaminate ground beef.
Question 3 of 5
The nurse is assessing a client who has a sacral pressure ulcer. The wound has partial thickness, loss of dermis, and a red-pink wound bed. No slough is present. How would the nurse chart this wound?
Correct Answer: B
Rationale: A partial-thickness ulcer with loss of dermis and a red-pink bed is Stage II. Stage I is non-blanchable redness, Stage III involves full-thickness loss, and Stage IV exposes muscle or bone.
Question 4 of 5
The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?
Correct Answer: A
Rationale: Hemolytic anemia causes red blood cell destruction, leading to bilirubin buildup and jaundice, which is specific to this type. Anorexia, tachycardia, and fatigue are nonspecific.
Question 5 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although the client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders?
Correct Answer: B
Rationale: narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure