NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
Correct Answer: C
Rationale: This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. Sacral pressure will counteract the pressure created by the position of the fetal head. The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
Question 2 of 5
The nurse is performing an assessment on a client with a history of a thyroidectomy. Which finding suggests the client is experiencing hypocalcemia?
Correct Answer: A
Rationale: Hypocalcemia post-thyroidectomy (due to parathyroid damage) causes muscle twitching or tetany from low calcium levels. Nausea, chest pain, and fever are less specific.
Question 3 of 5
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
Correct Answer: C
Rationale: The most immediate action in cases of suspected fetal distress or hyperstimulation during labor induction with Pitocin is to stop the Pitocin infusion to reduce uterine stimulation and improve fetal oxygenation. Other actions like vaginal exams or pushing are inappropriate without further assessment, and positioning is secondary.
Question 4 of 5
A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?
Correct Answer: B
Rationale: Muscle cramps and exhaustion after intense exercise suggest hyponatremia due to excessive sweating and water intake, diluting sodium levels. Hypernatremia (
A) causes neurological symptoms, hyperkalemia (
C) causes arrhythmias, and hypokalemia (
D) causes weakness but is less likely without diuretic use.
Question 5 of 5
A client with a history of hepatitis C is admitted with complaints of fatigue. The nurse should expect the client to have:
Correct Answer: A
Rationale: Hepatitis C causes liver inflammation, leading to elevated liver enzymes (e.g., AST, ALT), a common finding reflecting hepatic damage.