NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
What is the appropriate nursing action for a child with increased intracranial pressure?
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.
Question 2 of 5
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
Question 3 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 4 of 5
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
Question 5 of 5
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.