NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
Question 2 of 5
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
Correct Answer: B
Rationale: Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. The estrogen-progesterone assay test is used to identify present tumors being fed from an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
Question 3 of 5
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
Correct Answer: A
Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.
Question 4 of 5
The physician has ordered a 24-hour urine collection for a client. Which instruction should the nurse provide?
Correct Answer: A
Rationale: For a 24-hour urine collection, the first void is discarded, and all subsequent urine is collected for exactly 24 hours to ensure accurate measurement of analytes. A single container is used, refrigeration is advised, but separate voids are not needed.
Question 5 of 5
A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?
Correct Answer: D
Rationale: Favorite objects from home assist in creating a familiar setting, preventing or minimizing separation anxiety.