NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.
Question 2 of 5
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
Correct Answer: A
Rationale: Rapidly moving from one topic to another without following any logical sequence is called flight of ideas, characteristic of manic behavior.
Question 3 of 5
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale. When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
Correct Answer: B
Rationale: The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. The foramen ovale is located in the atrial septum of the heart and does not affect the liver. The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
Question 4 of 5
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?
Correct Answer: B
Rationale: Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question 5 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.