NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:
Correct Answer: C
Rationale: Ampicillin is a safe antibiotic for pyelonephritis in pregnancy, with no known teratogenic effects.
Question 2 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 3 of 5
A student in a cardiac unit is performing auscultation of a client’s heart. Which stethoscope placement would indicate to the nurse that the student is performing pulmonic auscultation correctly?
Correct Answer: C
Rationale: The pulmonic valve is auscultated at the second intercostal space, left of the sternum. Apex/sternum (
A) is nonspecific, fifth intercostal space (
B) is for the mitral valve, and manubrium (
D) is not a standard site.
Question 4 of 5
A client has ascites, which is caused by:
Correct Answer: A
Rationale: A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity.
Question 5 of 5
A new diabetic is learning to administer his insulin. He receives 10 units of NPH insulin and 12 units of regular insulin each morning. Which of the following statements reflects understanding of the nurse's teaching?
Correct Answer: A
Rationale: When mixing regular and NPH insulin in one syringe, regular (clear) insulin is drawn first to prevent contamination of the regular insulin vial with NPH (cloudy). They can be mixed, so two injections are unnecessary.