NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
Correct Answer: A
Rationale: Fluid volume deficit is the major problem. Symptoms of dehydration are evident, and rehydration is critical to prevent life-threatening complications.
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
The nurse is caring for a client with cancer of the pancreas. Which finding indicates involvement of the bile ducts?
Correct Answer: A
Rationale: Pancreatic cancer can obstruct bile ducts causing bilirubin buildup and dark urine (bilirubinuria). Petechiae indicate bleeding dark stools suggest GI bleeding and steatorrhea reflects fat malabsorption not bile duct involvement.
Question 4 of 5
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
Correct Answer: C
Rationale: The bleeding ulcer can be life-threatening, emphasizing the need to address the physical threat posed by the psychophysiological disorder.
Question 5 of 5
The nurse is providing discharge teaching for a client taking naltrexone (Revia). The nurse should instruct the client to avoid which over-the-counter medication:
Correct Answer: C
Rationale: Naltrexone, used for opioid or alcohol dependence, can interact with cold medicines containing dextromethorphan, which may have opioid-like effects, reducing naltrexone’s efficacy. Acetaminophen, ibuprofen, and antihistamines do not have significant interactions.