NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 2 of 5
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?
Correct Answer: C
Rationale: A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. Epinephrine decreased inspiratory difficulty by stimulating α-, β1, and β2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). The person with asthma fights to inspire sufficient air thus increasing respiratory rate.
Question 3 of 5
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
Correct Answer: A
Rationale: Diminished femoral pulses in a newborn suggest coarctation of the aorta, a cardiac anomaly, due to reduced blood flow to the lower extremities. The other findings are normal or nonspecific.
Question 4 of 5
The nurse is caring for a client who is receiving oxytocin for labor induction. The fetal heart rate shows variable decelerations. The nurse’s first action should be to:
Correct Answer: B
Rationale: Variable decelerations suggest umbilical cord compression. Repositioning the client (e.g. to the left side or knee-chest position) may relieve compression and is the first action. Stopping oxytocin or notifying the physician may be needed if repositioning is ineffective.
Question 5 of 5
The nurse is performing an assessment on a newborn with suspected coarctation of the aorta. Which finding is most likely?
Correct Answer: A
Rationale: Coarctation of the aorta causes narrowed aortic flow, leading to diminished femoral pulses. Murmurs may occur, but pulse discrepancy is most characteristic.