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Free NCLEX RN Questions
A 25-year-old client arrives in the emergency room with a possible fracture of the right femur. The nurse should anticipate an order for
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Bryant's traction
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Ice to the entire extremity
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Buck's traction
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An abduction pillow
Explanation
Correct Answer C. Buck's traction
Explanation:
For an adult client with a suspected femur fracture, Buck’s traction is often used. It is a form of skin traction applied to the lower extremity to reduce muscle spasms, immobilize the limb, and prevent further injury until surgical repair can be performed. It helps maintain alignment and control pain before definitive treatment.
Why the other options are incorrect:
A. Bryant's traction
This is used for young children with femur fractures, not for adults. It involves both legs being suspended vertically.
B. Ice to the entire extremity
Applying ice may be part of initial management for swelling and pain, but it is not the primary immobilization method for a femur fracture.
D. An abduction pillow
An abduction pillow is typically used after hip replacement surgery to prevent hip dislocation, not for femur fractures.
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves
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XII (hypoglossal)
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X (vagus)
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IX (glossopharyngeal)
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VII (facial)
Explanation
Correct Answer C. IX (glossopharyngeal)
Explanation:
The gag reflex is mediated primarily by the glossopharyngeal nerve (cranial nerve IX), which provides the sensory (afferent) pathway, and the vagus nerve (cranial nerve X), which provides the motor (efferent) response. Absence of the gag reflex usually indicates dysfunction of CN IX.
Why the other options are incorrect:
A. XII (hypoglossal)
This controls tongue movement, not the gag reflex.
B. X (vagus)
While CN X contributes to the motor portion of the gag reflex, the loss of the reflex is most commonly attributed to damage of CN IX (sensory pathway).
D. VII (facial)
This nerve controls facial expressions, taste (anterior tongue), and salivary glands, not the gag reflex.
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to
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Notify the physician
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Make sure the catheter is patent
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Administer an antihypertensive
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Provide supplemental oxygen
Explanation
Correct Answer B. Make sure the catheter is patent
Explanation:
Autonomic hyperreflexia (also called autonomic dysreflexia) is a life-threatening emergency that occurs in clients with spinal cord injuries at or above T6. The most common trigger is a distended bladder from a blocked or kinked urinary catheter. After elevating the head of the bed to reduce blood pressure, the nurse must immediately check and relieve the cause, beginning with ensuring catheter patency.
Why the other options are incorrect:
A. Notify the physician
This is important but should occur after immediate nursing interventions to remove the trigger. Waiting to notify the physician without addressing the cause delays treatment.
C. Administer an antihypertensive
Antihypertensives may be required if blood pressure remains dangerously high, but the first priority is to remove the precipitating stimulus (commonly bladder distention).
D. Provide supplemental oxygen
Oxygen is not the primary intervention. The main concern is the noxious stimulus causing the hypertensive crisis, which must be removed first.
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for
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A client with Alzheimer's disease
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A client with pneumonia
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A client with cirrhosis
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A client with thrombophlebitis
Explanation
Correct Answer A. A client with Alzheimer's disease
Explanation:
The nursing assistant can be assigned to care for clients who require basic supportive care, such as assistance with activities of daily living, feeding, hygiene, and safety measures. A client with Alzheimer’s disease may require supervision, help with personal care, and assistance with routine tasks, which fall within the nursing assistant’s scope of practice.
Why the other options are incorrect:
B. A client with pneumonia
This client requires frequent respiratory assessments, monitoring of oxygen status, and possible administration of medications, all of which require an RN or LPN.
C. A client with cirrhosis
Clients with cirrhosis often have complex care needs, including monitoring for ascites, bleeding tendencies, and hepatic encephalopathy. This requires licensed nursing judgment.
D. A client with thrombophlebitis
This condition requires frequent assessment for complications such as pulmonary embolism, as well as administration of anticoagulants, which cannot be delegated to a nursing assistant.
A client is admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram the nurse should
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Obtain a history of prior cardiac problems
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Begin an IV using a large-bore catheter
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Administer oxygen at 2 L per minute via nasal cannula
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Perform pupil checks for size and reaction to light
Explanation
Correct Answer C. Administer oxygen at 2 L per minute via nasal cannula
Explanation:
The priority in suspected myocardial infarction (MI) is to optimize oxygen supply to the heart muscle. After obtaining an ECG to confirm the diagnosis, the nurse should immediately administer oxygen (usually 2–4 L/min by nasal cannula) to prevent further hypoxia and myocardial damage. This aligns with the initial emergency management steps for chest pain: MONA (Morphine, Oxygen, Nitroglycerin, Aspirin).
Why the other options are incorrect:
A. Obtain a history of prior cardiac problems
While history is important, it is not the immediate priority when a client presents with crushing chest pain and possible MI.
B. Begin an IV using a large-bore catheter
IV access is necessary for medications, but oxygen administration takes priority to prevent worsening ischemia.
D. Perform pupil checks for size and reaction to light
This assessment is not immediately relevant in the acute management of chest pain and possible MI.
A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition
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Widening pulse pressure
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Decrease in the pulse rate
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Dilated, fixed pupils
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Decrease in level of consciousness
Explanation
Correct Answer D. Decrease in level of consciousness
Why this is the correct answer:
The earliest and most sensitive indicator of increased intracranial pressure (ICP) is a change in the client’s level of consciousness. This occurs because rising ICP decreases cerebral perfusion, leading to early cerebral dysfunction. Subtle signs like confusion, restlessness, or lethargy may be observed before vital sign changes or pupillary abnormalities. Early recognition is critical to prevent further neurological deterioration.
Why the other options are incorrect:
A. Widening pulse pressure
This is part of Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations), which indicates late and severe increased ICP, not an early sign.
B. Decrease in the pulse rate
Bradycardia also appears in Cushing’s triad as a late sign of increased ICP. It suggests significant brainstem pressure, which occurs after earlier changes in LOC.
C. Dilated, fixed pupils
Pupil changes are also a late sign, typically indicating herniation or severe brainstem involvement. By this stage, the client’s condition is already critical.
A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with
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A positive blood
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B positive blood
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O negative blood
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AB negative blood
Explanation
Correct Answer C. O negative blood
Why this is the correct answer:
Clients with B negative blood type can only safely receive blood that does not introduce the Rh factor and that is compatible with their ABO type. O negative blood is known as the universal donor because it lacks both A and B antigens as well as the Rh factor, making it the safest alternative when type-specific blood (B negative) is unavailable.
Why the other options are incorrect:
A. A positive blood
This contains A antigens and the Rh factor, making it incompatible and likely to trigger a serious transfusion reaction.
B. B positive blood
Although it has the correct B antigen, it contains the Rh factor. Since the client is Rh negative, exposure could lead to hemolytic reactions and antibody development.
D. AB negative blood
This contains both A and B antigens. A client with type B blood would recognize the A antigen as foreign, leading to incompatibility and risk of reaction.
The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is MOST IMPORTANT for the charge nurse to implement
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A bed near the nursing station
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Four-point leather restraints
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Minimizing environmental stimuli
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One-on-one supervision from a sitter
Explanation
Correct Answer D. One-on-one supervision from a sitter
Why this is the correct answer:
Acute delirium carries a high risk of falls, pulling lines/catheters, wandering, and accidental self-harm. Continuous, dedicated observation by a trained sitter provides immediate, moment-to-moment intervention—redirecting, reorienting, preventing unsafe ambulation, and summoning help instantly. It is the most effective single measure to prevent injury while underlying causes (e.g., UTI) are treated. Best-practice delirium bundles prioritize constant supervision and nonpharmacologic strategies before restraints or sedatives.
Why the other options are incorrect:
A. A bed near the nursing station
Proximity improves surveillance, but nurses have multiple patients and may be briefly unavailable. It reduces—but does not eliminate—risk. Continuous, dedicated observation by a sitter offers superior, uninterrupted protection and rapid response for an agitated, confused elder.
B. Four-point leather restraints
Physical restraints can worsen delirium, increase agitation, raise the risk of aspiration, pressure injuries, and even serious trauma. They are last-resort, time-limited measures when all safer options fail and there is immediate danger. They are not the primary, most important safety intervention.
C. Minimizing environmental stimuli
Lowering noise, dimming lights at night, clustering care, and promoting sleep are helpful delirium measures, but they do not provide continuous protection against immediate hazards. Without constant observation, an agitated patient can still fall or remove devices. A sitter more directly ensures safety.
A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the PRIORITY nursing intervention
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Ask if the client needs to use the bedpan
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Assess the client’s fluid intake
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Assess the client’s skin turgor
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Palpate the client’s suprapubic area
Explanation
Correct Answer D. Palpate the client’s suprapubic area
Why this is the correct answer:
Morphine can cause urinary retention by increasing sphincter tone and decreasing the sensation of bladder fullness. When a client has not voided for several hours, the nurse’s immediate priority is to assess for bladder distention. Palpating the suprapubic area provides critical information on whether the bladder is full and supports next steps such as bladder scanning or catheterization.
Why the other options are incorrect:
A. Ask if the client needs to use the bedpan
The issue is likely retention rather than inability to access toileting. Simply asking does not address the underlying cause or provide objective assessment.
B. Assess the client’s fluid intake
Fluid balance is important, but the priority is determining whether urine is being retained, not just consumed. Intake alone does not confirm urinary retention.
C. Assess the client’s skin turgor
Skin turgor assesses hydration status. While useful, it does not address the urgent problem of possible bladder distention and retention due to opioid use.
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is
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Right ventricular hypertrophy
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Cardiac dysrhythmia
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Left ventricular hypertrophy
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Hyperkalemia
Explanation
Correct Answer B. Cardiac dysrhythmia
Explanation:
The most common complication after a myocardial infarction (MI) is cardiac dysrhythmia, occurring in up to 90% of patients. Ischemia and infarcted tissue disrupt the normal electrical conduction of the heart, leading to arrhythmias such as PVCs, ventricular tachycardia, or ventricular fibrillation. Dysrhythmias can be life-threatening and are a major cause of sudden death after MI.
Why the other options are incorrect:
A. Right ventricular hypertrophy
This condition is usually caused by chronic pulmonary hypertension or lung disease (cor pulmonale), not an acute MI.
C. Left ventricular hypertrophy
This develops gradually from chronic hypertension or aortic stenosis, not acutely following an MI.
D. Hyperkalemia
Potassium imbalances may occur with renal dysfunction or certain medications but are not the most common complication after an MI.
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