NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?
Correct Answer: A
Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.
Question 2 of 5
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is:
Correct Answer: C
Rationale: March 27 is a miscalculation. February 1 is a miscalculation. February 27 is the correct answer.
To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. January 3 is a miscalculation.
Question 3 of 5
The nurse is caring for a client with a diagnosis of abruptio placenta. Which nursing intervention is most appropriate?
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making monitoring fetal heart tones the most appropriate intervention to assess fetal well-being. Oxygen Trendelenburg and fluids are secondary based on clinical findings.
Question 4 of 5
Before giving methergine postpartum, the nurse should assess the client for:
Correct Answer: B
Rationale: Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. Flushing is not a side effect of methergine. Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
Question 5 of 5
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:
Correct Answer: A
Rationale: It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it.