NCLEX-RN
NCLEX RN Practice Questions Quizlet 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 requires immediate assessment of fetal heart tones to evaluate fetal well-being.
Question 2 of 5
A client is to wear a Holter monitor for continuous cardiac monitoring for 48 hours. The nurse should advise the client to avoid which of the following activities during the monitoring period? Select all that apply.
Correct Answer: C,D
Rationale: Holter monitors can be affected by electromagnetic interference from wireless devices like iPads (
C), so these should be avoided. Showering and bathing (
D) can damage the monitor or electrodes. Watching TV (
A), using a remote control (
B), drinking caffeine (E), and exercising (F) typically do not interfere with monitoring, though exercise should be noted in the activity log.
Question 3 of 5
The nurse is preparing to administer digoxin (Lanoxin) 0.25 mg IV to a client with heart failure. Prior to administration, the nurse checks the client’s apical pulse and finds it to be 52 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as it can exacerbate bradycardia
Question 4 of 5
A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?
Correct Answer: A
Rationale: Pancreatic cancer often leads to malnutrition due to impaired digestion and absorption, making alteration in nutrition the primary concern.
Question 5 of 5
A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:
Correct Answer: B
Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%; assuming only the anterior trunk is affected (18%), the total TBSA is 27%, but 35% is the closest reasonable estimate for partial and full-thickness burns.