NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves?
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and larynx, contributing to the gag reflex. Absence of the gag reflex suggests vagus nerve injury. Hypoglossal (XII) controls tongue movement, glossopharyngeal (IX) aids taste and swallowing, and facial (VII) controls facial muscles.
Question 2 of 5
The client has an order for sliding scale insulin at 1900 hours and Lantus (glargine) insulin at the same hour. The nurse should:
Correct Answer: B
Rationale: Lantus (glargine) is a long-acting insulin and should not be mixed with short-acting sliding scale insulin (e.g. regular insulin) due to differing pharmacokinetics. Administering them in separate injections ensures proper action profiles.
Question 3 of 5
Which of the following statements applies to the care of the client hospitalized with influenza?
Correct Answer: B, C, E
Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (
B), keeping equipment in the room (
C), and wearing a mask for direct care (E). N-95 masks (
A) are for airborne diseases (e.g., T
B). The door should remain closed (
D) to limit droplet spread.
Question 4 of 5
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
Correct Answer: A
Rationale: This answer is correct. A balanced diet with adequate salt intake is necessary. This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000-3000 mL/day). This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
Question 5 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.