NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:
Correct Answer: C
Rationale: March 27 is a miscalculation. February 1 is a miscalculation. February 27 is the correct answer.
To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. January 3 is a miscalculation.
Question 2 of 5
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
Question 3 of 5
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
Correct Answer: D
Rationale: Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus. (A, B,
C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
Question 4 of 5
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question 5 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.