Questions 149

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NCLEX RN Practice Exam Questions

Question 1 of 5

For which of the following reasons would the nurse use the Braden Scale to assess a client?

Correct Answer: B

Rationale: The Braden Scale assesses risk for pressure sores (
B) by evaluating factors like mobility and skin moisture. It is not used for delirium (
A), falls (
C), or substance abuse (
D).

Question 2 of 5

The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?

Correct Answer: D

Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.

Question 3 of 5

The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client's right to emergency services, regardless of ability to pay, is provided by which piece of legislation?

Correct Answer: D

Rationale: The Emergency Medical Treatment and Active Labor Act (EMTAL
A) ensures that emergency services are provided regardless of ability to pay, not the options listed.

Question 4 of 5

The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?

Correct Answer: B

Rationale: Low urinary output (20 mL/hour) may indicate renal impairment or hypoperfusion, requiring further investigation.

Question 5 of 5

A client has been diagnosed with immune thrombocytic purpura (ITP). Which of the following signs and symptoms indicate increased thrombocytopenia? Select all that apply.

Correct Answer: A,B

Rationale: ITP causes low platelets, leading to nosebleeds (
A) and petechiae/bruising (
B). Vision changes (
C), numbness (
D), and confusion (E) are not typical.

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