NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Question 2 of 5
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
Correct Answer: A
Rationale: Amphotericin B should be mixed with D5W, not normal saline, due to stability issues. Slow infusion (
B), hydration (
C), and premedication (
D) are standard practices.
Question 3 of 5
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
Question 4 of 5
Which nursing assessment indicates that involutional changes have occurred in a client who is three days postpartum?
Correct Answer: A
Rationale: A firm fundus three finger widths below the umbilicus by day three postpartum indicates normal uterine involution, as the uterus contracts and descends.
Question 5 of 5
Upon arrival to the nursery, Ilotycin (erythromycin) eyedrops are instilled in the newborn's eyes. The nurse understands that the medication will:
Correct Answer: B
Rationale: Erythromycin eyedrops are used prophylactically in newborns to prevent ophthalmia neonatorum, which can cause blindness.