NCLEX-RN
RN NCLEX Practice Test Questions
Question 1 of 5
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
Correct Answer: A
Rationale: Chest drainage of 150 mL/hour post-CABG suggests significant bleeding, requiring immediate reporting to prevent hypovolemia. Confusion, pallor, and low urine output are less urgent.
Question 2 of 5
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
Question 3 of 5
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
Correct Answer: A
Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.
Question 4 of 5
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.
Question 5 of 5
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
Correct Answer: A
Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.