NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
Question 2 of 5
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
Correct Answer: B
Rationale: Raising the side rails ensures client safety, preventing falls, especially if the client is attempting to sit up.
Question 3 of 5
A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Mirtazapine commonly causes weight gain.
Question 4 of 5
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
Question 5 of 5
When giving a client a tube feeding the nurse should:
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.