NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
The nurse recognizes all of the following as part of the Cushing reflex triad EXCEPT
Correct Answer: A
Rationale: Cushing reflex (response to increased intracranial pressure) includes hypertension, bradycardia, and irregular respirations. Cardiac arrhythmia is not part of the triad.
Question 2 of 5
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
Correct Answer: D
Rationale: Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
Question 3 of 5
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?
Correct Answer: A
Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.
Question 4 of 5
A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.
Question 5 of 5
The nurse is taking care of an elderly client with congestive heart failure. Which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? Select all that apply.
Correct Answer: A, B, D
Rationale: Daily weights monitor fluid status, assistance with self-care reduces exertion, and post-activity vital signs assess heart workload. Sensory stimulation may increase stress.