NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
When assessing the client's blood pressure, the nurse should use a cuff with a width that is __% of the circumference of the extremity. (Fill in the blank.)
Correct Answer: 40
Rationale: The blood pressure cuff width should be approximately 40% of the extremity’s circumference to ensure accurate readings. A cuff too narrow or wide can falsely elevate or lower readings.
Question 2 of 5
Which of the following factors affects the accuracy of pulse oximetry readings?
Correct Answer: A, B, C
Rationale: Pulse oximetry accuracy is reduced by poor circulation (
A), improper probe placement (
B), and bright lighting (
C). Dark skin (
D) has minimal impact with modern sensors.
Question 3 of 5
The nurse is discharging a client with a prescription of eyedrops.
Correct Answer: B
Rationale: Administering a second eyedrop immediately (
B) prevents absorption of the first, indicating a need for teaching (wait 5–10 minutes). Shaking (
A), hand washing (
C), and proper instillation (
D) are correct.
Question 4 of 5
A client has ataxia following a cerebral vascular accident. The nurse should:
Correct Answer: A
Rationale: Ataxia post-stroke causes unsteady gait, increasing fall risk. Supervising ambulation ensures safety. Intake/output, speech therapy, and writing aids are unrelated to ataxia.
Question 5 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.