NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Correct Answer: B
Rationale: Amniotic fluid is generally pale and straw colored. Meconium-stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
Question 2 of 5
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
Correct Answer: A
Rationale: This answer is correct. If the cause is removed, the delirious client will recover completely. This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
Question 3 of 5
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
Correct Answer: C
Rationale: The most immediate action in cases of suspected fetal distress or hyperstimulation during labor induction with Pitocin is to stop the Pitocin infusion to reduce uterine stimulation and improve fetal oxygenation. Other actions like vaginal exams or pushing are inappropriate without further assessment, and positioning is secondary.
Question 4 of 5
The nurse is assessing the client with metabolic alkalosis. Which findings would likely be observed in this client?
Correct Answer: B, C, E, F
Rationale: Metabolic alkalosis results from excess bicarbonate or loss of acids (e.g., from vomiting). Vomiting and nausea (
C) are common causes. Numbness (
B), circumoral paresthesia (E), and hypertonic muscle contractions (F) occur due to hypocalcemia from alkalosis. Kussmaul’s respirations (
A) are associated with metabolic acidosis, and warm flushed skin (
D) is unrelated.
Question 5 of 5
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
Correct Answer: A
Rationale: Diminished femoral pulses in a newborn suggest coarctation of the aorta, a cardiac anomaly, due to reduced blood flow to the lower extremities. The other findings are normal or nonspecific.