NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 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.
Question 2 of 5
A client is 6 weeks pregnant. During her first prenatal visit, she asks, 'How much alcohol is safe to drink during pregnancy?' The nurse's response is:
Correct Answer: D
Rationale: No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. The recommended safe dosage of alcohol consumption during pregnancy is none.
Question 3 of 5
A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?
Correct Answer: D
Rationale: Cholestyramine binds bile acids in the intestine, forming complexes excreted in stool, reducing circulating bile acids that cause itching. It doesn’t block histamine (
A), inhibit enzymes (
B), or reduce gallbladder bile (
C).
Question 4 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 5 of 5
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
Correct Answer: C
Rationale: (
Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.