NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
Question 2 of 5
At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:
Correct Answer: A
Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.
Question 3 of 5
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
Correct Answer: A
Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.
Question 4 of 5
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:
Correct Answer: B
Rationale: Gravida=3 (current pregnancy), Para=2 (two births after 20 weeks).
Question 5 of 5
The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:
Correct Answer: A
Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.