NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will 'beat out of her chest.' The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:
Correct Answer: C
Rationale: An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. The blood administration should take place over the ordered time frame designated by the physician.
Question 2 of 5
Which nursing intervention would be of highest priority when caring for a patient admitted in sickle cell vaso-occlusive crisis?
Correct Answer: D
Rationale: In sickle cell vaso-occlusive crisis severe pain results from blocked blood vessels. Administering pain medication is the highest priority to relieve acute discomfort and improve patient comfort. While IV fluids and oxygen are important pain management is the most urgent need.
Question 3 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
Question 4 of 5
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:
Correct Answer: C
Rationale: March 27 is a miscalculation. February 1 is a miscalculation. February 27 is the correct answer.
To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. January 3 is a miscalculation.
Question 5 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.