NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
Question 2 of 5
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
Correct Answer: A
Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C,
D) The other responses are not expected in this situation and are not even side effects.
Question 3 of 5
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.
Question 4 of 5
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.
Question 5 of 5
The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:
Correct Answer: A
Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.