NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.
Question 2 of 5
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid 'vena caval syndrome,' a condition which:
Correct Answer: B
Rationale: Vena caval syndrome occurs when the gravid uterus compresses the inferior vena cava, slowing blood return from the extremities.
Question 3 of 5
A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
Correct Answer: C
Rationale: Air embolism is suspected. Placing the client in the left lateral decubitus position traps air in the right atrium, preventing pulmonary embolism. Notifying the physician (
A), elevating the bed (
B), or changing fluids (
D) is secondary.
Question 4 of 5
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?
Correct Answer: A
Rationale: Meperidine crosses the placental barrier and can cause respiratory depression in the fetus, making it inappropriate for preoperative cesarean delivery.
Question 5 of 5
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
Correct Answer: B
Rationale: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.