NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
Question 2 of 5
A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
Question 3 of 5
A client is taking Deltasone (prednisone) each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
Correct Answer: D
Rationale: Prednisone is taken in the morning to mimic the body’s natural cortisol peak, which occurs early in the day, minimizing adrenal suppression and side effects. Timing does not primarily affect forgetting, fluid retention, or absorption.
Question 4 of 5
The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet. Puffed wheat contains gluten and should be avoided. Bananas, puffed rice, and cornflakes (if certified gluten-free) are typically safe.
Question 5 of 5
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.