NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
Question 2 of 5
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.
Question 3 of 5
Which stage of labor lasts from delivery of the baby to delivery of the placenta?
Correct Answer: B
Rationale: This stage is from complete dilatation of the cervix to delivery of the fetus. This is the correct stage for the definition. This stage lasts for about 2 hours after the delivery of the placenta. There is no fifth stage of labor.
Question 4 of 5
A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?
Correct Answer: C
Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.
Question 5 of 5
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
Correct Answer: C
Rationale: The client will have minimal difficulty swallowing after a vertical partial laryngectomy, indicating effective preoperative teaching. Special swallowing training is typically required for supraglottic (horizontal partial) laryngectomy, not vertical. Voice quality will be altered, and radical neck dissection is associated with total laryngectomy.