NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 2 of 5
A client with a history of diverticulitis complains of abdominal pain, fever, and diarrhea. Which food is most likely responsible for the client's symptoms?
Correct Answer: D
Rationale: Whole-grain cereal, high in fiber and seeds, can irritate diverticulitis, causing pain, fever, and diarrhea. Low-fiber foods like potatoes, carrots, and fish are less likely to trigger symptoms.
Question 3 of 5
The nurse is caring for a client with a diagnosis of hyperemesis gravidarum. Which intervention is most appropriate?
Correct Answer: D
Rationale: Hyperemesis gravidarum requires IV fluids for hydration small frequent meals to reduce nausea and antiemetics to control vomiting. All interventions are appropriate to manage symptoms and prevent complications.
Question 4 of 5
The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
Correct Answer: A
Rationale: Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. Quickening is the mother's perception of fetal movement and generally does not occur until 18-20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. During the first trimester there should be only a modest weight gain of 2-4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.
Question 5 of 5
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
Correct Answer: A
Rationale: Abdominal assessment follows the sequence: inspection, auscultation, palpation. Auscultation is done before palpation to avoid altering bowel sounds. Inspection identifies visible abnormalities first.