NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.
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 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.
Question 4 of 5
The nurse is teaching a client with a history of chronic kidney disease about dietary modifications. The nurse should tell the client to:
Correct Answer: A
Rationale: Limiting phosphorus intake prevents bone and cardiovascular complications in chronic kidney disease.
Question 5 of 5
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.