Free NCLEX RN Practice Questions
Question 1 of 5.
The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.
A. assist the client back to bed
B. complete an incident report
C. notify the health care provider
D. assess the client for any injuries
E. document in the medical record that the client fell
Explanation: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.
Question 2 of 5.
A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
A. I have been helping my family deal with their feelings about the surgery.
B. I have been having difficulty coping with the surgery and cry frequently.
C. I have been unable to leave the house or talk to my friends about the surgery.
D. I am doing just great since the surgery and have gone back to work at my job.
Explanation: normal reaction one month later
Question 3 of 5.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
A. The child is placed in a private room.
B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
D. The staff uses standard precautions.
Explanation: contact precautions required for diapered or incontinent clients
Question 4 of 5.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
A. Remove the dressing and replace it with a more absorbent dressing.
B. Collect a culture and sensitivity specimen of the drainage.
C. Observe the wound for dehiscence.
D. Reinforce the dressing with an 8x10 dressing.
Explanation: expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry
Question 5 of 5.
The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
A. Supine with legs abducted.
B. High Fowler’s with legs extended.
C. Side-lying on the unaffected side.
D. Prone with legs adducted.
Explanation: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement