NCLEX RN Practice Test
Question 1 of 5.
The nurse is caring for a client with suspected meningitis who will be having a lumbar puncture. Which statement regarding aftercare is correct?
A. Specimen jars should be labeled and numbered and taken to the laboratory immediately and refrigerated.
B. The nurse should position the client with the head of the bed up 20 degrees so the client can drink fluids to replace CSF removed during the procedure.
C. The nurse should put the client in the low semi-Fowler's position with a pillow under her abdomen to increase intra-abdominal pressure.
D. The nurse should assess for numbness, tingling, pain at injection site, movement of the extremities, any drainage at the site, and the ability to void.
Explanation: Post-lumbar puncture care includes assessing for neurological changes, pain, drainage, and voiding to detect complications like nerve injury or CSF leak.
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