NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:
Correct Answer: B
Rationale: Discomfort with ankle dorsiflexion is not expected with meningitis. Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. Discomfort with wrist flexion is not expected with meningitis. Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
Question 2 of 5
A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation?
Correct Answer: A
Rationale: Compensatory shock involves normal BP (120/70), tachycardia (HR 120), and early neurological changes (confusion). Options B, C, and D indicate progressive or irreversible shock with severe symptoms.
Question 3 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 4 of 5
The nurse is teaching a client in preparation for a colonoscopy. Which would be involved in the teaching session?
Correct Answer: A, C, E
Rationale: Colonoscopy prep includes a liquid diet (
A), laxative bowel prep (
C), and NPO 8 hours prior (E). Sedation is standard (
B), and enemas (
D) are not routine on admission.
Question 5 of 5
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
Correct Answer: C
Rationale: Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. Rice contains about 4 g of protein per 200 g. Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. Green beans only contain 2 g of protein per cup.