NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (
B), oral care (
C), and breathing exercises (
D) are supportive but less critical for ICP control.
Question 2 of 5
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
Correct Answer: A
Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.
Question 3 of 5
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.
Question 4 of 5
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
Question 5 of 5
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
Correct Answer: B
Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.