NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
Correct Answer: C
Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.
Question 2 of 5
A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is:
Correct Answer: A
Rationale: Autonomic dysreflexia, a life-threatening exaggerated sympathetic response, can occur in spinal cord injuries above T6, causing severe hypertension.
Question 3 of 5
The client is admitted at 32 weeks gestation with a diagnosis of gestational hypertension. Which assessment finding is most significant?
Correct Answer: A
Rationale: Proteinuria of 2+ is a significant finding in gestational hypertension as it suggests progression to preeclampsia which can lead to severe complications. BP of 140/90 edema and weight gain are concerning but less specific without proteinuria.
Question 4 of 5
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.
Question 5 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.