NCLEX RN· Full Length · Practice NCLEX RN Test
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
Expert Explanatory Rationale
Correct Answer: Place the client in a prone position 15-30 minutes twice a day
Prone positioning helps stretch hip flexors, preventing contractures after AKA by maintaining proper alignment.
A client's blood pressure is 132/84. What is the mean arterial pressure?
Expert Explanatory Rationale
Correct Answer: 92 mmHg
Mean arterial pressure (MAP) = [systolic + (2 ÷ diastolic)] ÷ 3. Calculation: [132 + (2 ÷ 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
The nurse has just administered an IM injection to a client. In which of the following ways should the nurse dispose of the needle?
Expert Explanatory Rationale
Correct Answer: discard the needle in a puncture-resistant container in the client's room
Needles should be disposed of immediately in a puncture-resistant container in the client’s room to minimize sharps injury risk.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
Expert Explanatory Rationale
Correct Answer: Hallucinogenic drugs induce a state of altered perception.
Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.
A nursing instructor demonstrates to several students how to wrap an amputated limb in a bandage using a figure eight technique. Which of the following correctly states the benefits of this technique? Select all that apply.
Expert Explanatory Rationale
Correct Answer:
The figure-eight technique reduces swelling (B) by promoting venous return and minimizes pain (C) by stabilizing the limb. It does not prevent clots (A) or air exposure (D).
The chest tube drainage system has continuous bubbling in the water seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for:
Expert Explanatory Rationale
Correct Answer: An air leak
Continuous bubbling in the water seal chamber indicates an air leak, either from the lung or the system. Clamping helps locate the source of the leak.
A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?
Expert Explanatory Rationale
Correct Answer: Instruct the client that he might be asked to cough and breathe deeply during the procedure
During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.
The '5 A's' of smoking cessation intervention begin with which of the following?
Expert Explanatory Rationale
Correct Answer: Ask all clients about tobacco use at every visit.
The 5 A's begin with Ask (B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
Expert Explanatory Rationale
Correct Answer: voriconazole (Vfend)
Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
Which statement by the client regarding sickle cell disease indicates a need for further teaching?
Expert Explanatory Rationale
Correct Answer: I can enjoy one glass of red wine per day.
Alcohol, including red wine, can cause dehydration and increase the risk of sickle cell crisis, so it should be avoided. Other statements are correct.
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