NCLEX-RN
NCLEX RN Fundamental Questions Questions
Question 1 of 5
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.
Extract:
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
Question 2 of 5
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing --------------based on the client’s------------------------
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
Extract:
Question 3 of 5
The nurse is caring for a client admitted with severe pre-eclampsia. It would be essential for the nurse to have which of the following items at the bedside?
Correct Answer: D
Rationale: Severe pre-eclampsia increases seizure risk (eclampsia), requiring suction equipment at the bedside to manage airway secretions during a seizure. Saline, gloves, and ultrasound are not immediate priorities for seizure management.
Question 4 of 5
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)?
Correct Answer: B
Rationale: An INR of 3.5 indicates a high bleeding risk, critical for surgical safety, and must be reported to the PHCP. Elevated HbA1c, normal hematocrit, and low BUN are less urgent but may still require attention.
Question 5 of 5
The nurse is assessing a client with a history of chronic pain. Which chronic pain assessment focuses on wellness?
Correct Answer: B
Rationale: A wellness-focused chronic pain assessment includes medical history, pain symptoms, and psychosocial factors to optimize quality of life. Birth history, religion, or sensory deficits alone are insufficient.