NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a closed head injury. Fluid is assessed leaking from the ear. The nurse's first action will be to:
Correct Answer: C
Rationale: Fluid leaking from the ear may indicate cerebrospinal fluid (CSF) leakage, a serious complication. Testing for glucose (positive in CSF) is the first step to confirm the nature of the drainage.
Question 2 of 5
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Correct Answer: A
Rationale: The phlebostatic axis (4th intercostal space, mid-axillary line) is the standard reference point for accurate central venous pressure measurement.
Question 3 of 5
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
Correct Answer: C
Rationale: Assuming a wide, regular, rapid rhythm (common in critical scenarios), ventricular tachycardia is the most likely arrhythmia, requiring immediate intervention.
Question 4 of 5
The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
Correct Answer: C
Rationale: Head measurement (e.g., head circumference) is the most objective, quantifiable data for assessing hydrocephalus, unlike subjective symptoms like anorexia or vomiting.
Question 5 of 5
Which of the following diet instructions should be given to the client with recurring urinary tract infections?
Correct Answer: D
Rationale: Cranberry juice acidifies urine, reducing bacterial growth and preventing urinary tract infections.