NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
Correct Answer: C
Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.
Question 2 of 5
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.
Question 3 of 5
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
Correct Answer: D
Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
Question 4 of 5
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question 5 of 5
The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.