NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:
Correct Answer: A
Rationale: Vaginal bleeding in labor may indicate placental abruption or previa both of which threaten fetal well-being. Assessing fetal heart tones is the first action to ensure fetal stability before further evaluation.
Question 2 of 5
At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
Correct Answer: A
Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.
Question 3 of 5
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
Correct Answer: D
Rationale: Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
Question 4 of 5
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
Question 5 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: B
Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C,
D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.