NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
Question 2 of 5
Which finding is associated with Tay Sachs disease?
Correct Answer: B
Rationale: Cherry-red spots on the macula are a classic finding in Tay-Sachs disease due to lipid accumulation in retinal ganglion cells.
Question 3 of 5
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
Question 4 of 5
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.
Question 5 of 5
A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.