NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).
Question 2 of 5
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb).
Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
Question 3 of 5
A client with a history of osteoarthritis is admitted with complaints of joint stiffness. The nurse should expect the client to have:
Correct Answer: A
Rationale: Osteoarthritis causes joint pain worsened by activity due to cartilage degeneration, unlike rheumatoid arthritis, which involves prolonged morning stiffness.
Question 4 of 5
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
Question 5 of 5
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
Correct Answer: A
Rationale: Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the 'living ligature.' A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.