NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 2 of 5
The client is admitted with a diagnosis of molar pregnancy. Which intervention is most appropriate?
Correct Answer: A
Rationale: Molar pregnancy involves abnormal trophoblastic tissue and no viable fetus often causing vaginal bleeding. Monitoring for bleeding is critical.
Tocolytics cesarean delivery and fetal monitoring are not indicated.
Question 3 of 5
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
Correct Answer: C
Rationale: Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. Betamethasone does not affect uteroplacental circulatory exchange.
Question 4 of 5
A client with a history of pneumonia is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Dyspnea in pneumonia indicates impaired gas exchange, so administering oxygen is the priority to improve oxygenation.
Question 5 of 5
A client with a history of hyperparathyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
Correct Answer: A
Rationale: Hyperparathyroidism increases parathyroid hormone, leading to hypercalcemia, causing fatigue and other symptoms.