NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 2 of 5
In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy?
Correct Answer: C
Rationale: Reducing the incidence of disease through education supports primary prevention.
Question 3 of 5
A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-MI due to ischemic damage to the conduction system. Hypertrophy develops later, and hyperkalemia is less common.
Question 4 of 5
When the nurse checks the fundus of a client on the first postpartum day,she notes that the fundus is firm level with the umbilicus and displaced to the side. The next action the nurse should take is to:
Correct Answer: A
Rationale: A displaced fundus on the first postpartum day is often due to bladder distention which pushes the uterus aside. Checking for bladder distention (e.g. by palpation or encouraging voiding) is the next step to correct the displacement.
Question 5 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Serum hCG levels are markedly elevated in gestational trophoblastic disease and ultrasound reveals a characteristic “snowstorm” pattern or grape-like vesicles. Both tests are essential for diagnosis.