NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
Correct Answer: A
Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.
Question 2 of 5
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which intervention is most appropriate?
Correct Answer: D
Rationale: Chorioamnionitis requires antibiotics for infection fetal heart tone monitoring for distress and preparation for delivery (vaginal or cesarean) if maternal or fetal condition worsens. All interventions are appropriate.
Question 3 of 5
A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:
Correct Answer: A
Rationale: Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. The limb has been immobilized already by the cast, and therefore immobilization is not a concern. Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.
Question 4 of 5
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
Question 5 of 5
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.