NCLEX Questions, Free NCLEX RN Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?

Correct Answer: B

Rationale: An RN has the authority to initiate seclusion based on clinical judgment.

Question 2 of 5

A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should:

Correct Answer: B

Rationale: A CVP of 2 cm of water is low, suggesting hypovolemia; slowing the IV infusion prevents fluid overload while addressing the issue.

Question 3 of 5

The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?

Correct Answer: A

Rationale: An arterial blood gas POâ‚‚ of 98 indicates adequate oxygenation, supporting cerebral perfusion, which is a favorable outcome for a subdural hematoma.

Question 4 of 5

A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered

Correct Answer: B

Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.

Question 5 of 5

The nurse is auscultating the apical pulse over the PMI (point of maximum impact). Which heart sounds would be audible?

Correct Answer: D

Rationale: S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) are normally audible at the PMI. S3 and S4 are less common and indicate pathology.

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