NCLEX RN Practice Questions
Question 1 of 5.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Explanation: The biceps reflex is elicited by placing the thumb on the biceps tendon in the antecubital space and tapping it with a reflex hammer.
Question 2 of 5.
A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
A. Allow the client to sleep undisturbed.
B. Administer oxygen via facemask or nasal prongs.
C. Administer naloxone (Narcan).
D. Place epinephrine 1:1,000 at the bedside.
Explanation: IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action
Question 3 of 5.
The nurse is caring for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST?
A. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
B. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
C. The physician calls the unit to ask the nurse to obtain a client’s latest serum electrolyte results from the lab.
D. The husband of a client reports to the nurse that his wife’s nose began bleeding after she returned from radiation therapy.
Explanation: should assess client to determine amount and cause of bleeding
Question 4 of 5.
The nurse’s INITIAL priority when managing a physically assaultive client is to
A. restrict the client to the room.
B. place the client under one-to-one supervision.
C. restore the client’s self-control and prevent further loss of control.
D. clear the immediate area of other clients to prevent harm.
Explanation: most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client’s self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client
Question 5 of 5.
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client
A. eat a high-protein, low-residue diet.
B. lie on her unoperated side.
C. exercise her arms and legs.
D. cough and deep breathe.
Explanation: prevents respiratory complications due to immobility following surgery
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