NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.
Question 2 of 5
The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?
Correct Answer: B
Rationale: This response is expected with metoclopramide, in addition to increasing gastric emptying.
Question 3 of 5
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
Correct Answer: A
Rationale: Fluid volume deficit is the major problem. Symptoms of dehydration are evident, and rehydration is critical to prevent life-threatening complications.
Question 4 of 5
The nurse is caring for a 3-month-old girl with meningitis. She has a positive Kernig's sign. The nurse expects her to react to discomfort if she:
Correct Answer: B
Rationale: Discomfort with ankle dorsiflexion is not expected with meningitis. Spinal flexion, flexing the neck or the hips with legs extended, causes discomfort if the meninges are irritated. Discomfort with wrist flexion is not expected with meningitis. Rotating the cervical spine may cause discomfort with meningitis, but pain with flexion is more indicative of meningeal irritation.
Question 5 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.