NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which of the following positions so the client can begin pushing?
Correct Answer: A
Rationale: Squatting with a C-shaped body facilitates pushing by aligning the pelvis and using gravity, ideal for the second stage of labor without anesthesia.
Question 2 of 5
The nurse is caring for a child with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority?
Correct Answer: B
Rationale: Hydration is the priority in vaso-occlusive crisis to reduce blood viscosity and promote circulation, preventing further sickling and complications.
Question 3 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 4 of 5
Your client has presented in the emergency department with a sudden onset of shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, neck, and back. Which of the following would you most likely suspect?
Correct Answer: C
Rationale: Sudden onset of these symptoms, especially chest and back pain, suggests a dissected thoracic aortic aneurysm, a life-threatening condition requiring urgent intervention.
Question 5 of 5
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.