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 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
Correct Answer: C
Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.
Question 3 of 5
The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
Question 4 of 5
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
Correct Answer: B
Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.
Question 5 of 5
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.