NCLEX RN Questions Fundamentals
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Question 1 of 5.
The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
A. Provide the client with opportunities to discuss their feelings.
B. Document the neurovascular assessments.
C. Assess the client's mood and affect.
D. Offer nutrition and hydration.
Explanation: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
Question 2 of 5.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
A. Perform range of motion with the client's left leg.
B. Obtain the client's temperature.
C. Assess the client for pain.
D. Administer prescribed oxycodone-acetaminophen.
Explanation: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.
Question 3 of 5.
The nurse has obtained a client's blood pressure. The nurse recognizes that which of the following factors may increase a client's blood pressure?
A. Nicotine patch application
B. Heat exhaustion
C. Performing deep breathing exercises
D. Hypothyroidism
Explanation: Nicotine, a vasoconstrictor, increases blood pressure. Heat exhaustion, deep breathing, and hypothyroidism typically lower or do not affect BP acutely.
Question 4 of 5.
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
A. Advances the walker 6-10 inches.
B. Has their elbow flexed 15-30 degrees.
C. Tilts the walker forward to help stand up from a chair.
D. Advances the walker and then the affected leg.
Explanation: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.
Question 5 of 5.
The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
A. Instructs the client to tilt the head backward when drinking.
B. Reminds the client to assume a chin-down position.
C. Provides rest periods as needed during the meal.
D. Positions the client upright for 30-60 minutes after a meal.
E. Positions the head of the bed at a 45-degree angle during the meal.
Explanation: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
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