NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 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 (located at the fourth intercostal space mid-axillary line) is the standard reference point for zeroing the manometer to accurately measure central venous pressure. The other options are incorrect anatomical landmarks.
Question 2 of 5
A patient with a PCA pump (patient controlled analgesia) asks the nurse if he can become overdosed with pain medication using this machine. Which statement made by the nurse is correct?
Correct Answer: B
Rationale: PCA pumps have a lockout interval and dose limits programmed to prevent overdose, ensuring safe administration of pain medication. The other statements are inaccurate: PCA requires patient action, does not deliver large doses every four hours, and is not based on ‘need’ detection.
Question 3 of 5
The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
Correct Answer: D
Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and decreased movement due to joint swelling and pain.
Question 4 of 5
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.
Question 5 of 5
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.