NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Correct Answer: B
Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.
Question 2 of 5
A vaginal exam reveals that the cervix is 4cm dilated,with intact membranes and a fetal heart tone rate of 160-170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
Correct Answer: B
Rationale: External fetal monitoring is appropriate when membranes are intact as internal monitoring requires ruptured membranes. The cervix is not closed fetal heart tones are normal and contraction intensity is irrelevant to external monitoring.
Question 3 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
Question 4 of 5
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age (macrosomic) due to maternal hyperglycemia and are at risk for hypoglycemia after birth due to high insulin levels. Hyperglycemia and small size are less common.
Question 5 of 5
A client tells the nurse that she has a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
Correct Answer: D
Rationale: Restricting fluid intake promotes urinary stasis, increasing infection risk. The other options are appropriate preventive measures.