NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
Correct Answer: D
Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
Question 2 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 3 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Postpartum endometritis a uterine infection can cause fever (from infection) tachycardia (from systemic response) and hypotension (in severe cases). All vital sign changes may be observed.
Question 4 of 5
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.
Question 5 of 5
The nurse is caring for a client with a closed head injury. Which finding should be reported to the doctor immediately?
Correct Answer: D
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration in a head injury, requiring immediate reporting. The other findings are within normal or less urgent ranges.