NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
Correct Answer: D
Rationale: A full bladder is the most common cause of uterine displacement; having the client void addresses this before further interventions.
Question 2 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 3 of 5
A terrorist attack has left hundreds of patients with injuries determined to be in the immediate category as defined by NATO. The color to designate this group is:
Correct Answer: C
Rationale: In NATO triage the immediate category (requiring urgent intervention to survive) is designated by red. Black indicates deceased or expectant yellow is delayed and green is minimal.
Question 4 of 5
Cheyne-Stokes respiratory pattern can be associated with which of the following conditions?
Correct Answer: C
Rationale: Cheyne-Stokes respiratory pattern is most often associated with increased intracranial pressure secondary to changes in pressure in the cerebral and cerebellar areas.
Question 5 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.