NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?
Correct Answer: C, E, F
Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.
Question 2 of 5
A client with AIDS has a viral load of 200 copies per mL. The nurse should interpret this finding as:
Correct Answer: C
Rationale: A viral load of 200 copies per mL is very low indicating effective antiretroviral therapy and minimal circulating virus. It does not directly assess opportunistic disease risk communicability or T-cell count.
Question 3 of 5
Prior to an amniocentesis, a fetal ultrasound is done in order to:
Correct Answer: C
Rationale: Amniocentesis involves removal of amniotic fluid for evaluation. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the position of the placenta and the fetus.
Question 4 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 5 of 5
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale. When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
Correct Answer: B
Rationale: The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed. The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. The foramen ovale is located in the atrial septum of the heart and does not affect the liver. The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.