NCLEX Practice Test RN

NCLEX Practice Test RN Related

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A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

  • A. Cullen's sign
  • B. Rebound tenderness
  • C. Murphy's sign
  • D. Turner's sign
Correct Answer: C

Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

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Before completing a nursing diagnosis, the nurse must first:

  • A. Write goals and objectives
  • B. Perform an assessment
  • C. Plan interventions
  • D. Perform evaluation
Correct Answer: B

Rationale: Assessment is the first step of nursing process.

A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:

  • A. Monitoring for infection
  • B. Administering pain medication
  • C. Monitoring blood pressure
  • D. Administering diuretics
Correct Answer: A

Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.

A client with a history of a deep vein thrombosis is receiving Warfarin (Coumadin). The nurse should teach the client to avoid:

  • A. Green leafy vegetables
  • B. Dairy products
  • C. Citrus fruits
  • D. High-fat foods
Correct Answer: A

Rationale: Green leafy vegetables are high in vitamin K, which antagonizes warfarin’s anticoagulant effect. Dairy, citrus, and high-fat foods do not significantly affect warfarin.

A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

  • A. Infection postoperatively
  • B. Malignant hyperthermia
  • C. Neuroleptic malignant syndrome
  • D. Fever postoperatively
Correct Answer: B

Rationale: Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.

The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?

  • A. Exploratory laparotomy with a colon resection the previous shift
  • B. Client with a stroke who has been hospitalized for two days
  • C. A client with metastatic cancer on PCA morphine
  • D. A new admission with diverticulitis
Correct Answer: B

Rationale: A stable stroke client (hospitalized for two days) is appropriate for a nursing assistant, who can assist with basic care (e.g., hygiene, mobility). Recent surgery (A), PCA morphine (C), and new admissions (D) require higher-level nursing skills.

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