NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
Correct Answer: B
Rationale: Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk.
Question 2 of 5
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
Correct Answer: C
Rationale: A mechanical soft diet is easier to chew and swallow due to its consistent texture, making it appropriate before trying a puréed diet.
Question 3 of 5
When assessing a client, the nurse notes the typical skin rash seen with systemic lupus erythematosus. Which of the following descriptions correctly describes this rash?
Correct Answer: D
Rationale: The appearance of small, round or oval reddish brown macules scattered over the entire body is characteristic of rubeola. The appearance of scattered clusters of macules, papules, and vesicles throughout the body is characteristic of chickenpox. Palmar redness is seen in clients with cirrhosis of the liver. The characteristic butterfly rash over the cheek and nose and into the scalp is seen with systemic lupus erythematosus.
Question 4 of 5
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Question 5 of 5
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.