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 client with a cervical dilation of 8cm suddenly becomes short of breath,cyanotic and hypotensive. The nurse should suspect which of the following complications?
Correct Answer: A
Rationale: Amniotic fluid embolus is a rare but life-threatening complication characterized by sudden dyspnea cyanosis and hypotension due to amniotic fluid entering the maternal circulation. These symptoms are not typical of transition phase abruption or cord prolapse.
Question 3 of 5
The best diagnostic test for treponema pallidum is:
Correct Answer: C
Rationale: The fluorescent treponemal antibody (FT
A) test is the most specific and sensitive for detecting Treponema pallidum (syphilis). VDRL and RPR are non-treponemal tests used for screening and Thayer-Martin culture is for gonorrhea.
Question 4 of 5
A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:
Correct Answer: A
Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.
Question 5 of 5
A client with hyperthyroidism is taking Eskalith (lithium carbonate) to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication?
Correct Answer: B
Rationale: Increased thirst and urination suggest lithium toxicity, as lithium can cause polyuria and polydipsia. Blurred vision and weight gain are less specific, and rhinorrhea is unrelated.