NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station +2 means that the:
Correct Answer: C
Rationale: Station +2 means the presenting part is 2 cm below the ischial spines, indicating descent in the pelvis.
Question 2 of 5
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.
Question 3 of 5
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
Correct Answer: A
Rationale: Increased, dilute urine post-pituitary surgery suggests diabetes insipidus due to decreased antidiuretic hormone, requiring immediate physician notification.
Question 4 of 5
Why is Phytonadione (vitamin K) administered to a newborn shortly after birth?
Correct Answer: D
Rationale: Newborns have low vitamin K levels, necessary for clotting factor synthesis. Phytonadione is given to facilitate clotting and prevent hemorrhagic disease of the newborn. It does not stop active hemorrhage, treat infections, or replace electrolytes.
Question 5 of 5
The client is prescribed prednisone for an acute exacerbation of lupus. Which side effect should the nurse monitor for?
Correct Answer: C
Rationale: Prednisone, a corticosteroid, can cause hypertension due to sodium retention and vasoconstriction. Hyperglycemia (not hypoglycemia), weight gain, and tachycardia are more likely than weight loss or bradycardia.