NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.
Question 2 of 5
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
Correct Answer: A
Rationale: Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in most individuals. Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. Occlusion of the circumflex artery does not cause bradycardia. Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.
Question 3 of 5
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Question 4 of 5
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
Question 5 of 5
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
Correct Answer: B
Rationale: This statement is entirely false. Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. Although the cause of phantom pain is still unknown, these measures may promote the relief of any type of pain, not just phantom pain. Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.