NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
Correct Answer: C
Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.
Question 2 of 5
A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:
Correct Answer: D
Rationale: Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup urine disease, and Lowe's syndrome. Metachromatic stain is a laboratory test that may be used to diagnose Tay-Sachs and other lipid diseases of the central nervous system. The blood serum phenylalanine test is diagnostic of phenylketonuria and can be used for wide-scale screening. A lecithin-sphingomyelin ratio of at least 2:1 is indicative of fetal lung maturity, and survival of the fetus is likely.
Question 3 of 5
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?
Correct Answer: C
Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
Question 4 of 5
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Question 5 of 5
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (
B), oral care (
C), and breathing exercises (
D) are supportive but less critical for ICP control.