NCLEX-RN
NCLEX RN Practice Test Free Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
Question 2 of 5
The nurse is caring for a client 7 days post-burn injury with 60% body surface area involved. The nursing care of this client would primarily focus on:
Correct Answer: A
Rationale: At 7 days post-burn, infection is a major risk due to open wounds and immunosuppression, making meticulous infection control the primary focus.
Question 3 of 5
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
Correct Answer: A
Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.
Question 4 of 5
The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
Correct Answer: D
Rationale: Oliguria may indicate diabetes insipidus, a common complication after pituitary surgery due to antidiuretic hormone deficiency.
Question 5 of 5
A client is being treated with internal radiation (brachytherapy). The nurse explains to the client that
Correct Answer: C
Rationale: Brachytherapy requires distance precautions; visitors must stay 6 feet away to minimize radiation exposure. Gowns/masks are not needed, visitors are allowed, and gifts do not become radioactive.