NCLEX-RN
NCLEX RN Practice 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:
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.
Question 2 of 5
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
Question 3 of 5
A nurse has delegated care of a client in wrist restraints to a nursing assistant. The nursing assistant should check the skin circulation under the restraints at least
Correct Answer: C
Rationale: Restraints require circulation checks every 1-2 hours to prevent skin breakdown or neurovascular injury. Hourly checks (
C) balance safety and practicality.
Question 4 of 5
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
Question 5 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:
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.