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
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 3 of 5
Before administering intravenous chemotherapy to the patient being treated, the nurse should:
Correct Answer: C
Rationale: Chemotherapy often causes nausea and vomiting, so administering an antiemetic prophylactically is standard to improve patient comfort. Fluid boluses, pain medication, or eating are not routine pre-chemotherapy steps unless specified.
Question 4 of 5
The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?
Correct Answer: C
Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.
Question 5 of 5
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
Correct Answer: B
Rationale: This statement represents a short-term goal. Long-term therapy should be directed toward assisting the client to cope effectively with stress. Suicide contracts represent short-term interventions. This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.