NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
Question 2 of 5
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
Question 3 of 5
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
Correct Answer: D
Rationale: Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
Question 4 of 5
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most characteristic?
Correct Answer: A
Rationale: Postpartum endometritis causes foul-smelling lochia due to uterine infection. Painless bleeding suggests other causes fetal distress is irrelevant postpartum and hypotension occurs only in severe cases.
Question 5 of 5
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.