NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
Correct Answer: C
Rationale: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
Question 2 of 5
A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:
Correct Answer: C
Rationale: This nursing action may cause hyperventilation. This nursing action could cause inferior vena cava syndrome. The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications.
Question 3 of 5
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
Correct Answer: C
Rationale: This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. Sacral pressure will counteract the pressure created by the position of the fetal head. The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
Question 4 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.
Question 5 of 5
The therapeutic blood-level range for lithium is:
Correct Answer: B
Rationale: This range is too low to be therapeutic. This is the therapeutic range for lithium. This range is above the therapeutic level. This range is toxic and may cause severe side effects.