NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client with a history of a stroke is being discharged. The nurse should teach the client to:
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.
Question 2 of 5
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
Order the Items
Source Container
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).
Question 3 of 5
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
Correct Answer: C
Rationale: Pursed-lip breathing helps blow off CO2 and keep air passages open, reducing shortness of breath. Increasing O2 too high may remove the breathing stimulus, and the other options are not appropriate.
Question 4 of 5
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
Question 5 of 5
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.