NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client with a history of asthma is admitted with an acute exacerbation. The nurse should give priority to:
Correct Answer: A
Rationale: Bronchodilators are the first-line treatment for an acute asthma exacerbation to relieve bronchospasm and improve airflow.
Question 2 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.
Question 3 of 5
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
Correct Answer: C
Rationale: A deficit in sodium concentration results in muscular weakness and lethargy. Muscle fatigue and hypotonia are caused by hypercalcemia. Muscle weakness and fatigue are classic signs of hypokalemia. Hypermagnesemia can cause muscle weakness, paralysis, and coma.
Question 4 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 5 of 5
A client with a history of polycystic kidney disease has an order for an indwelling catheter. The nurse should give priority to:
Correct Answer: A
Rationale: Sterile technique during catheter insertion is critical in polycystic kidney disease to prevent urinary tract infections, which can worsen renal function. Bag position and clamping are secondary.