NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
Question 2 of 5
The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant?
Correct Answer: B
Rationale: Providing routine catheter care is within the scope of a nursing assistant, as it involves basic hygiene tasks, unlike the other options, which require advanced assessment or monitoring.
Question 3 of 5
The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?
Correct Answer: C
Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.
Question 4 of 5
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, 'What does salt have to do with high blood pressure?' the nurse's initial response would be:
Correct Answer: B
Rationale: Excess salt causes fluid retention, increasing blood volume and thus blood pressure.
Question 5 of 5
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will be included in the teaching plan?
Correct Answer: B
Rationale: A Foley catheter is inserted during cervical radiation implants to keep the bladder empty, reducing radiation exposure. TV/phone use (
A) is allowed, high-fiber diet (
C) is not specific, and excretions (
D) are not radioactive with internal implants.