NCLEX Practice Test RN
Question 1 of 5.
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
A. Place a tongue blade in the child's mouth.
B. Restrain the child so he will not injure himself.
C. Go to the nurses station and call the physician.
D. Move furniture out of the way and place a blanket under his head.
Explanation: The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. Restraining the child's movements could cause constrictive injury. Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. The nurse should provide safety for the child by moving objects and protecting the head.
Question 2 of 5.
A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:
A. Oral itching after eating bananas
B. Swelling of the eyes and mouth
C. Difficulty in breathing
D. Swelling and itching of the hands
Explanation: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.
Question 3 of 5.
During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
A. Libel
B. Slander
C. Malpractice
D. Negligence
Explanation: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
Question 4 of 5.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
A. Decreased blood pressure and constricted pupils
B. Increased heart rate and increased respirations
C. Increased respirations and increased blood pressure
D. Anoxia and absence of the cough reflex
Explanation: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
Question 5 of 5.
During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:
A. Assess the drainage bag.
B. Check for bladder distention.
C. Unclamp the tubing.
D. Irrigate the tubing.
Explanation: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.
Related Questions