NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:
Correct Answer: C
Rationale: This nursing action may cause hyperventilation. This nursing action could cause inferior vena cava syndrome. The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications.
Question 2 of 5
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
Correct Answer: A
Rationale: The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him--Alcoholics Anonymous.
Question 3 of 5
A client with Hodgkin's lymphoma is receiving Platinol (cisplatin). To help prevent nephrotoxicity, the nurse should:
Correct Answer: B
Rationale: Cisplatin is nephrotoxic, and adequate hydration helps dilute the drug and protect the kidneys, reducing the risk of renal damage.
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
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.