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
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 3 of 5
Which of the following is the best indicator of the diagnosis of HIV?
Correct Answer: C
Rationale: The Western blot is the confirmatory test for HIV diagnosis, detecting specific antibodies with high specificity. ELISA is a screening test, while WBC and CBC are non-specific and not diagnostic for HIV.
Question 4 of 5
The nurse is caring for a client with a diagnosis of placenta previa. Which intervention is most appropriate?
Correct Answer: A
Rationale: Bedrest minimizes bleeding risk in placenta previa by reducing cervical pressure.
Tocolytics are not typically used vaginal delivery is contraindicated and antibiotics are not indicated unless infection is present.
Question 5 of 5
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 50 gtt/min.