NCLEX RN Practice Test
Question 1 of 5.
A client pushes his call light and tells the nurse his chest is hurting. The nurse sees his oxygen saturation is 88%. The nurse's first intervention is to
A. perform an ECG.
B. administer oxygen.
C. administer morphine IV.
D. call the Rapid Response Team.
Explanation: Hypoxemia (SpO2 88%) requires immediate oxygen administration to improve oxygenation, which is the priority for chest pain before further assessment or intervention.
Question 2 of 5.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
A. Take the client to the dining room with 1:1 supervision.
B. Inform the client he may go to the dining room when he controls his behavior.
C. Hold the meal until the client is able to come out of seclusion.
D. Serve the meal to the client in the seclusion room.
Explanation: should eat at regular time; remain in the seclusion room for client’s safety
Question 3 of 5.
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
A. Sit up for at least 30 minutes after eating.
B. Avoid fluids between meals.
C. Increase the intake of high-carbohydrate foods.
D. Avoid eating large meals that are high in simple sugars and liquids.
Explanation: basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates
Question 4 of 5.
The nurse assesses the development of a three-month-old boy in the well-baby clinic. Which of the following behaviors, if observed by the nurse, would be UNEXPECTED?
A. The boy holds his head erect when sitting on the examination table.
B. The boy tries to grasp a toy just out of reach.
C. The boy turns his head to try to locate a sound.
D. The boy smiles spontaneously when he sees his mother.
Explanation: unexpected until 6 months of age
Question 5 of 5.
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?
A. Unequal and dilated pupils.
B. Decerebrate posturing.
C. Grand mal seizures.
D. Decreased level of consciousness.
Explanation: may be confused and stuporous