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
The physician has prescribed metoclopramide (Reglan). When assessing the client, the nurse would expect to find which of the following responses?
Correct Answer: B
Rationale: This response is expected with metoclopramide, in addition to increasing gastric emptying.
Question 3 of 5
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
Correct Answer: D
Rationale: A full bladder is the most common cause of uterine displacement; having the client void addresses this before further interventions.
Question 4 of 5
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
Correct Answer: C
Rationale: Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
Question 5 of 5
A client is admitted with a ruptured spleen following a four-wheeler accident. In preparation for surgery, the nurse suspects that the client is in the compensatory stage of shock because of which clinical manifestation?
Correct Answer: A
Rationale: Compensatory shock involves normal BP (120/70), tachycardia (HR 120), and early neurological changes (confusion). Options B, C, and D indicate progressive or irreversible shock with severe symptoms.