NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
Which set of vital signs would best indicate an increase in intracranial pressure?
Correct Answer: A
Rationale: Increased intracranial pressure (ICP) is indicated by Cushing's triad: widened pulse pressure (e.g., BP 180/70), bradycardia (pulse 50), and irregular respirations. Temperature elevation may occur but is less specific.
Question 2 of 5
While interviewing a client who abuses alcohol, the nurse learns that the client has experienced 'blackouts.' The wife asks what this means. The best response at this time is:
Correct Answer: A
Rationale: Blackouts in alcohol abuse refer to short-term memory amnesia, where the client cannot recall events during intoxication despite appearing conscious.
Question 3 of 5
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?
Correct Answer: D
Rationale: A grand mal seizure is the intended therapeutic effect of ECT, indicating effective treatment for severe depression.
Question 4 of 5
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, which is critical for ileostomy care.
Question 5 of 5
A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?
Correct Answer: B
Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.