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NCLEX RN· Reduction of Risk Potential · RN Reduction of Risk Potential NCLEX

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client?

A. Tell me when you feel me touch your arm.
B. Tell me when you stop hearing the tuning fork sound.
C. Do you have problems with balance?
D. How much is two plus four plus seven?

Expert Explanatory Rationale

Correct Answer: How much is two plus four plus seven?

Question 2 of 5

A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?

A. failure to track with the eyes
B. crying without tear production
C. bruising to the arms and shoulders
D. greater-than-expected head circumference and bulging fontanels

Expert Explanatory Rationale

Correct Answer: greater-than-expected head circumference and bulging fontanels

Question 3 of 5

The nurse is caring for a client who just had an arteriovenous (AV) fistula placed for dialysis. The nurse is providing home care instructions to the client. Which statement by the client indicates a need for further teaching by the nurse?

A. I should avoid wearing a watch on my arm with the fistula.
B. It may take several weeks before the fistula is ready to use.
C. I should not have my blood pressure taken in my access arm.
D. I should wear tight sleeves to protect and support the fistula so I don't bend it.

Expert Explanatory Rationale

Correct Answer: I should wear tight sleeves to protect and support the fistula so I don't bend it.

Question 4 of 5

The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?

A. inspection, auscultation, palpation, percussion
B. inspection, palpation, percussion, auscultation
C. inspection, percussion, auscultation, palpation
D. inspection, percussion, palpation, auscultation

Expert Explanatory Rationale

Correct Answer: inspection, auscultation, palpation, percussion

Question 5 of 5

The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.

A. epistaxis
B. petechiae
C. vomiting blood
D. elevated hematocrit
E. increased platelet count

Expert Explanatory Rationale

Correct Answer:

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