NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
Question 2 of 5
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
Correct Answer: A
Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
Question 3 of 5
A client with a history of seizure disorder is admitted with complaints of breakthrough seizures. The nurse should give priority to:
Correct Answer: A
Rationale: Administering anticonvulsants is the priority to control breakthrough seizures and prevent status epilepticus.
Question 4 of 5
A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
Correct Answer: C
Rationale: Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
Question 5 of 5
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.