NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
Correct Answer: C
Rationale: Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. Betamethasone does not affect uteroplacental circulatory exchange.
Question 2 of 5
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.
Question 3 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.
Question 4 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 5 of 5
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
Correct Answer: D
Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.