NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with an acoustic neuroma brain tumor. The location of this tumor warrants which of the following nursing diagnosis as the highest priority?
Correct Answer: D
Rationale: An acoustic neuroma affects the vestibulocochlear nerve, causing balance and hearing issues, increasing fall risk. High risk for injury is the priority due to potential for harm.
Question 2 of 5
The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
Correct Answer: B
Rationale: Flushing the IV tubing with insulin and discarding the first 50 mL prevents insulin binding to the tubing, ensuring accurate dosing.
Question 3 of 5
The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:
Correct Answer: B
Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.
Question 4 of 5
The nurse is evaluating the client's pulmonary artery pressure. The nurse is aware that this test evaluates:
Correct Answer: B
Rationale: A pulmonary artery catheter measures the systolic, diastolic, and mean pressures of the pulmonary artery.
Question 5 of 5
A nurse is working with an immobile client and doing passive range-of-motion (ROM) exercises on his legs. The client states the exercise is too painful and does not want to continue. The nurse should
Correct Answer: D
Rationale: Pain during ROM exercises may indicate injury. Stopping the exercise prevents harm, with further assessment or pain management to follow.