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NCLEX RN· Full Length · NCLEX RN Practice

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Showing all 10 practice questions with expert explanatory rationales.

Question 1 of 10

A client has returned from having a bronchoscopy. Before offering the client sips of water, the nurse should assess the client's:

A. Blood pressure
B. Pupilary response
C. Gag reflex
D. Pulse rate

Expert Explanatory Rationale

Correct Answer: Gag reflex

Question 2 of 10

A tornado warning has been issued in the area surrounding the hospital. Which action by the nurse is most appropriate to ensure client safety?

A. leave window blinds open so that staff can monitor the weather
B. close blinds, roll client beds out into the hallway, and close the doors to all the rooms
C. close window blinds and leave client doors open so the nurse can hear if a client calls out
D. leave blinds open but turn beds away from the windows and place as far away as possible from windows

Expert Explanatory Rationale

Correct Answer: close blinds, roll client beds out into the hallway, and close the doors to all the rooms

Question 3 of 10

The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?

A. A 50-year-old with a fractured fibula
B. A 20-year-old female with a wrist fracture
C. A 21-year-old male with a fractured femur
D. An 8-year-old with a fractured arm

Expert Explanatory Rationale

Correct Answer: A 21-year-old male with a fractured femur

Question 4 of 10

The physician has ordered lab work for a client with suspected disseminated intravascular coagulation (DIC). Which lab finding would provide a definitive diagnosis of DIC?

A. Elevated erythrocyte sedimentation rate
B. Prolonged clotting time
C. Presence of fibrin split compound
D. Elevated white cell count

Expert Explanatory Rationale

Correct Answer: Presence of fibrin split compound

Question 5 of 10

An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to:

A. Keep crackers at the bedside for eating before she arises
B. Drink a glass of whole milk before going to sleep at night
C. Skip breakfast but eat a larger lunch and dinner
D. Drink a glass of orange juice after adding a couple of teaspoons of sugar

Expert Explanatory Rationale

Correct Answer: Keep crackers at the bedside for eating before she arises

Question 6 of 10

The nurse would recognize which symptom as the most likely early indication of pneumonia in an elderly client?

A. chest pain
B. fever
C. dyspnea
D. altered mental status

Expert Explanatory Rationale

Correct Answer: altered mental status

Question 7 of 10

The nurse is reviewing labs on a client receiving IV heparin and notes an INR of 4.6. Which order by the health care provider does the nurse anticipate?

A. an order for vitamin K IM
B. an order for protamine sulfate
C. an order to redraw labs in 6 hours
D. an order to increase the infusion rate

Expert Explanatory Rationale

Correct Answer: an order for protamine sulfate

Question 8 of 10

A client diagnosed with gout 10 years ago admits she has never treated her gout and hoped it would just go away. The nurse knows all of the following are potential complications from untreated gout EXCEPT

A. kidney stones.
B. nodules of uric acid under the skin.
C. deformed joints.
D. peripheral neuropathy.

Expert Explanatory Rationale

Correct Answer: peripheral neuropathy.

Question 9 of 10

The nurse is admitting a new client to the medical unit. When asked about advance directives, the client says, 'I'm not really sure what that is, but I trust my doctor to do whatever he thinks I need.' Which is the correct action by the nurse?

A. tell the client not to worry about it, because the client can always add the advance directives later
B. tell the client that she can pay her lawyer to draw one up and have a copy sent to the hospital
C. explain what advance directives are and how they benefit the client, and offer to give the client a copy so she can read it and ask questions
D. omit further discussion about advance directives, and chart that the client does not have one and refuses further information

Expert Explanatory Rationale

Correct Answer: explain what advance directives are and how they benefit the client, and offer to give the client a copy so she can read it and ask questions

Question 10 of 10

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?

A. Enlarged spleen
B. Elevated blood pressure
C. Bradycardia
D. Beefy tongue

Expert Explanatory Rationale

Correct Answer: Beefy tongue

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