NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 13-year-old hemophiliac is hospitalized for hemarthrosis of his right knee. To relieve the pain, the nurse should:
Correct Answer: A
Rationale: Bed rest, elevation, and splinting reduce bleeding and pain in hemarthrosis, stabilizing the joint.
Question 2 of 5
The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
Correct Answer: A
Rationale: Cloudy dialysate returns suggest peritonitis, a serious complication of peritoneal dialysis, requiring immediate medical attention.
Question 3 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 4 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.
Question 5 of 5
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
Correct Answer: D
Rationale: Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points. TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.