NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A physician's order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using a microdrip tubing set. How many drops per minute should the nurse administer?
Correct Answer: C
Rationale: 50 gtt/min.
Question 2 of 5
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose 'just 5 more lb.' Her symptoms are consistent with:
Correct Answer: D
Rationale: All symptoms and vital signs are consistent with anorexia nervosa.
Question 3 of 5
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
Correct Answer: D
Rationale: If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
Question 4 of 5
The nurse has just received a report from the previous shift.
Correct Answer: B
Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. COPD with PCO2 50 (
A) is stable, pain (
C) is less urgent, and mild fever (
D) is expected post-op.
Question 5 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.