NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as:
Correct Answer: B
Rationale: 1 oz = 30 mL; therefore, 18 oz = 540 mL.
Question 2 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
Question 3 of 5
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, 'My life is so bad no one can do anything to help me.' The most helpful initial response by the nurse would be:
Correct Answer: C
Rationale: This response does not acknowledge the client's feelings and may increase his feelings of guilt. This response denotes false reassurance. This response acknowledges the client's feelings and invites a response. This response changes the subject and does not allow the client to talk about his feelings.
Question 4 of 5
A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:
Correct Answer: D
Rationale: Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire, ensuring a balanced diet.
Question 5 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Serum hCG levels are markedly elevated in gestational trophoblastic disease and ultrasound reveals a characteristic “snowstorm” pattern or grape-like vesicles. Both tests are essential for diagnosis.