NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?
Correct Answer: A
Rationale: Fetal and contraction monitoring is the priority to assess fetal well-being and labor progression, guiding further interventions.
Question 2 of 5
The nurse is admitting a client with a diagnosis of Guillain-Barre syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem?
Correct Answer: D
Rationale: Guillain-Barre syndrome is a clinical condition of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally it has been triggered by vaccination or surgery. The other options are not associated with an incidence of this syndrome.
Question 3 of 5
The nurse is caring for a client with a nasogastric tube. Which action confirms correct placement?
Correct Answer: A
Rationale: Checking the pH of aspirate (pH ‰¤ 5.5) confirms the tube is in the stomach, ensuring safe placement.
Question 4 of 5
A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.
Correct Answer: A,C,D
Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.
Question 5 of 5
Your client has a tube feeding. Which of the following commonly occurring complications of tube feedings can you prevent with the preventive measure that is coupled with it?
Correct Answer: C
Rationale: Maintaining a 30-45 degree angle during tube feedings reduces the risk of aspiration by preventing reflux of gastric contents.