NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
Correct Answer: C
Rationale: Identifying peripheral pulses is critical to assess baseline circulation, as an abdominal aortic aneurysm can affect distal blood flow.
Question 2 of 5
The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:
Correct Answer: B
Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.
Question 3 of 5
A client was transferred to the hospital unit as a direct admit from a small community hospital. While the nurse is obtaining part of the admission history information, the client suddenly becomes semiconscious. Assessment reveals a systolic BP of 70, heart rate of 130, and respiratory rate of 24. What is the nurse's initial action?
Correct Answer: B
Rationale: The client's symptoms suggest shock (low BP, high HR, elevated RR). Initiating an IV with a large bore needle allows for rapid fluid resuscitation, which is critical. Lowering the bed may worsen perfusion, notifying the physician delays action, and CPR is premature without pulselessness.
Question 4 of 5
A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation indicates an acute hemolytic reaction to the blood?
Correct Answer: A
Rationale: Low back pain is a hallmark of acute hemolytic transfusion reaction due to hemolysis and kidney involvement. Fever, urticaria, or neck vein distention suggest other complications.
Question 5 of 5
The nurse is caring for a 12-year-old client with appendicitis. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. What nursing action is most appropriate?
Correct Answer: D
Rationale: Notifying the physician respects the mother's beliefs while ensuring the medical team addresses the refusal appropriately.