NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?
Correct Answer: B
Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.
Question 2 of 5
Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis?
Correct Answer: B
Rationale: Meningitis in infancy can cause neurological damage, correlating with cerebral palsy.
Question 3 of 5
A 15-year-old client is rushed to the ER after taking an entire bottle of acetaminophen (Tylenol) in a suicide attempt. The nurse's priority is obtaining which lab results?
Correct Answer: A
Rationale: Acetaminophen overdose causes hepatotoxicity. AST and ALT levels assess liver damage, which is the priority.
Question 4 of 5
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
Correct Answer: A
Rationale: Pancreatic cancer often leads to malnutrition due to impaired digestion and absorption, making alteration in nutrition the primary concern.
Question 5 of 5
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
Correct Answer: C
Rationale: Assuming a wide, regular, rapid rhythm (common in critical scenarios), ventricular tachycardia is the most likely arrhythmia, requiring immediate intervention.