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 caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning an order for which of the following diagnostic tests?
Correct Answer: B
Rationale: A barium enema is contraindicated in suspected diverticulitis due to the risk of perforation and peritonitis. Ultrasound, CT scans, and CBC are appropriate for diagnosing diverticulitis or assessing complications.
Question 3 of 5
The client is prescribed tamsulosin (Flomax) for benign prostatic hyperplasia. Which side effect should the nurse monitor for?
Correct Answer: B
Rationale: Tamsulosin, an alpha-blocker, causes vasodilation, leading to orthostatic hypotension as a common side effect. Hypotension (not hypertension), bradycardia, and hyperglycemia are less likely.
Question 4 of 5
The nurse is caring for a client with a history of bipolar disorder. The nurse should give priority to:
Correct Answer: A
Rationale: Monitoring mood stability is critical in bipolar disorder to assess for manic or depressive episodes.
Question 5 of 5
The physician has ordered an amniocentesis to determine the L/S ratio. The L/S ratio is a reliable indicator of:
Correct Answer: C
Rationale: The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity by measuring surfactant levels in amniotic fluid. A ratio of 2:1 or higher indicates mature lungs reducing the risk of respiratory distress syndrome. It does not assess renal function Rh isoimmunization or anatomical abnormalities.