NCLEX RN Practice Tests
Question 1 of 5.
The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?
A. Altered level of consciousness is a late sign of increased ICP.'
B. Elevated temperature is the earliest indication of increased ICP.'
C. Late signs of increased ICP include narrowed pulse pressure and a lowered heart rate.'
D. Late signs of increased ICP include increased systolic blood pressure and a widened pulse pressure.'
Explanation: Late ICP signs include Cushing’s triad: increased systolic BP, widened pulse pressure, and bradycardia, reflecting brainstem compression.
Question 2 of 5.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
A. obtain respirations and temperature.
B. dilute with 9 ml of NS.
C. draw the medications in separate syringes.
D. verify the route of administration.
Explanation: Compazine should be considered incompatible in a syringe with all other medications
Question 3 of 5.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
A. The restraints/seclusion policies set forth by the institution.
B. The patient’s competence.
C. The patient’s voluntary/involuntary status.
D. The patient’s nursing care plan.
Explanation: the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status
Question 4 of 5.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
A. Promazine (Sparine).
B. Biperiden (Akineton).
C. Thiothixene (Navane).
D. Haloperidol (Haldol).
Explanation: is an antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing
Question 5 of 5.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?
A. Increase the oxygen flow to 4 L/min.
B. Administer a bronchodilator as ordered.
C. Place the client in a high Fowler’s position.
D. Obtain an arterial blood gas (ABG) sample.
Explanation: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment