NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
Correct Answer: B
Rationale: Consistent limit setting will help the client to know what is acceptable behavior, addressing the disruptive actions effectively.
Question 2 of 5
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Correct Answer: A
Rationale: A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. Proper identification of the recipient and the blood product must be validated by at least two people.
Question 3 of 5
A client with a history of gout is admitted with complaints of joint pain. The nurse should give priority to:
Correct Answer: A
Rationale: Anti-inflammatories (e.g., NSAIDs) relieve joint pain and inflammation in gout flares.
Question 4 of 5
A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Nägele's rule, the estimated date of confinement is:
Correct Answer: A
Rationale: Using Nägele's rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10.
Then add 7 days and 1 year, which would be March 17 of the following year. (B, C,
D) These dates are incorrect.
Question 5 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.