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
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
Correct Answer: A
Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (
A). Cognitive impairment (
B), vision impairment (
C), and anxiety (
D) do not typically present with these specific behaviors.
Question 3 of 5
The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
Correct Answer: A
Rationale: Raisins are lower in potassium compared to oranges, apricots, and bananas, making them suitable for a low-potassium diet.
Question 4 of 5
The nurse is reviewing a client's PRN pain medications. There is an order for acetaminophen 1,000 mg PO q4 hours as needed for pain. How should the nurse proceed?
Correct Answer: B
Rationale: Acetaminophen 1,000 mg q4 hours PRN is within safe dosing (max 4,000 mg/day), so it can be administered as ordered.
Question 5 of 5
The nurse is preparing to administer heparin to a client with a deep vein thrombosis. Which of the following laboratory values should the nurse check before administering the dose?
Correct Answer: B
Rationale: heparin’s therapeutic effect is monitored by aPTT, which should be 1.5–2 times the control value