NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 2 of 5
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
Correct Answer: D
Rationale: This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.
To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. IV fluids should be increased, not decreased. Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
Question 3 of 5
The nurse is performing a history on a client admitted for surgery in the morning. Which long-term medication in the client's history would be most important to report to the physician?
Correct Answer: A
Rationale: Prednisone, a corticosteroid, can affect wound healing, immune response, and adrenal function, requiring perioperative adjustments. Lisinopril (
B), Docusate (
C), and Oscal D (
D) are less likely to impact surgery acutely.
Question 4 of 5
A client has ascites, which is caused by:
Correct Answer: A
Rationale: A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity.
Question 5 of 5
A client has sustained a severe head injury and damaged the preoccipital lobe. The nurse should remain particularly alert for which of the following problems?
Correct Answer: A
Rationale: The preoccipital (occipital) lobe processes vision. Damage causes visual impairment (e.g., cortical blindness). Swallowing (
B) involves the brainstem, judgment (
C) the frontal lobe, and hearing (
D) the temporal lobe.