NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:
Correct Answer: C
Rationale: The test results were normal, so there would be no need to repeat to determine results. There are no data to indicate further tests are needed, because the result of the NST was normal. An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. The NST results were normal, so there was no fetal distress.
Question 2 of 5
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:
Correct Answer: B
Rationale: Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. The client has symptoms of dystonia but not of parkinsonism. The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.
Question 3 of 5
A client is newly diagnosed with diabetes. Which nursing diagnosis is a priority at this time?
Correct Answer: C
Rationale: For a newly diagnosed diabetic, deficient knowledge about disease management (e.g., diet, medication, monitoring) is the priority to ensure safe self-care. Fluid volume deficit, anxiety, and activity intolerance may apply but are secondary initially.
Question 4 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 5 of 5
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about pursed-lip breathing. Which statement indicates understanding?
Correct Answer: B
Rationale: Pursed-lip breathing involves slow exhalation through pursed lips to prolong exhalation and reduce air trapping in COPD. Quick inhalation (
A), breath-holding (
C), and rapid breathing (
D) are incorrect.