NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:
Correct Answer: A
Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.
Question 2 of 5
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
Correct Answer: B
Rationale: A moderate amount of clear amniotic fluid is expected after an amniotomy, indicating normal rupture of membranes.
Question 3 of 5
A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
Question 4 of 5
A 68-year-old client states he decided not to take the herpes zoster (shingles) immunization because his friend had the immunization and still developed shingles. Which of the following information should the nurse include when discussing this issue with the client? Select all that apply.
Correct Answer: B,C,D
Rationale: The shingles vaccine reduces severity (
B), postherpetic syndrome risk (
C), and shingles incidence by about 50% (
D). It doesn't eliminate risk (
A), and dismissing friends' advice (E) is inappropriate.
Question 5 of 5
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
Correct Answer: D
Rationale: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients