NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?
Correct Answer: B
Rationale: A high-protein diet is usually indicated because protein is excreted in urine. Protein restriction is usually prescribed with severe azotemia. The kidneys usually enlarge in these children, and sodium and water are retained. Fluid restriction may be ordered to help reduce edema; however, monitoring for dehydration is indicated. A high-cholesterol diet would not be indicated for any child, especially one with elevated blood pressure.
Question 2 of 5
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
Correct Answer: D
Rationale: If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
Question 3 of 5
A client with SIADH is admitted with severe hyponatremia. Which type of intravenous solution would the nurse expect to be ordered?
Correct Answer: B
Rationale: SIADH causes water retention and severe hyponatremia. Hypertonic 3% sodium chloride is used to correct low sodium levels by drawing water out of cells. Isotonic or hypotonic fluids may worsen hyponatremia and colloids are not indicated.
Question 4 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.
Question 5 of 5
After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20 minute test. The RN knows that these test results will be interpreted as:
Correct Answer: A
Rationale: A reactive nonstress test requires at least two accelerations of the fetal heart rate of at least 15 bpm, lasting 15 seconds, over a 20-minute period. The described results (5 bpm accelerations) do not meet the criteria, but the correct answer provided is A, indicating a possible error in the question's data. However, based on the provided answer, it is interpreted as reactive.