NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
While performing a neurological assessment on a client with a closed head injury, the nurse notes a positive Babinski reflex. The nurse should:
Correct Answer: D
Rationale: A positive Babinski reflex in an adult with a head injury suggests neurological damage, warranting immediate physician notification.
Question 2 of 5
A client arrives from surgery following an abdominal perineal resection with a permanent ileostomy. What should be the priority nursing care during the post-op period?
Correct Answer: D
Rationale: Facilitating perineal wound drainage is the priority to prevent infection and promote healing in the immediate postoperative period, as the perineal wound is at high risk for complications.
Question 3 of 5
The physician orders the removal of an in-dwelling catheter the second postoperative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that:
Correct Answer: D
Rationale: Pain and dribbling post-catheter removal are common due to bladder irritation and will typically improve within days.
Question 4 of 5
The home health nurse is scheduled to visit four clients. Which client should she visit first?
Correct Answer: A
Rationale: The AIDS client with fever and cough may have an acute infection like pneumonia, requiring urgent assessment.
Question 5 of 5
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
Correct Answer: B
Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.