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 is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
Correct Answer: A, C, D
Rationale: Creatine kinase (
A), myoglobin (
C), and troponin T (
D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (
B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
Question 3 of 5
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.
Question 4 of 5
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
Question 5 of 5
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.