NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
Correct Answer: C
Rationale: Vital signs are a high priority when working with self-destructive clients.
Question 2 of 5
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.
Question 3 of 5
The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
Question 4 of 5
A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months. A 7-pound newborn would weigh approximately 14 pounds at 6 months. The other weights are excessive or unrealistic.
Question 5 of 5
The nurse is assessing an adult female client for hypovolemia.
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (
B) and BUN (
D) are within normal ranges, and urine specific gravity (
C) is normal, not elevated as expected in hypovolemia.