NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease). The nurse should give priority to:
Correct Answer: A
Rationale: Respiratory muscle weakness in ALS can lead to respiratory failure, making respiratory status assessment the priority.
Question 2 of 5
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
Correct Answer: C
Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent obstruction or infection.
Question 3 of 5
A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?
Correct Answer: D
Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.
Question 4 of 5
A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?
Correct Answer: A
Rationale: Moving the client closer to the nursing station allows close monitoring without violating the client’s refusal of restraints, prioritizing safety and autonomy.
Question 5 of 5
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
Correct Answer: B
Rationale: The Whipple procedure is typically performed for pancreatic cancer in the head of the pancreas, involving resection of the pancreatic head, duodenum, and other structures.