NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
Correct Answer: C
Rationale: Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. Rice contains about 4 g of protein per 200 g. Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. Green beans only contain 2 g of protein per cup.
Question 2 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 3 of 5
Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client?
Correct Answer: A
Rationale: It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C,
D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.
Question 4 of 5
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
Correct Answer: C
Rationale: This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. Sacral pressure will counteract the pressure created by the position of the fetal head. The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
Question 5 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.