NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
Correct Answer: C
Rationale: Tetramune protects against diphtheria, pertussis, tetanus, and H. influenzae b and is part of a series given at 2, 4, 6, and 15-18 months. It does not test susceptibility or cover MMRV.
Question 2 of 5
A client with a history of sarcoidosis is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Sarcoidosis can cause lung granulomas, leading to dyspnea, so monitoring respiratory status is critical to assess lung function.
Question 3 of 5
The nurse is caring for a client with a history of a hip fracture who is in Buck’s traction. The nurse should:
Correct Answer: C
Rationale: In Buck’s traction, weights must hang freely off the floor to maintain proper traction force. Turning is limited, traction is not removed, and lotion is unnecessary.
Question 4 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which diagnostic test is most likely to be ordered?
Correct Answer: C
Rationale: Serum hCG levels are markedly elevated in gestational trophoblastic disease and ultrasound reveals a characteristic “snowstorm” pattern or grape-like vesicles. Both tests are essential for diagnosis.
Question 5 of 5
The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (MI) is that:
Correct Answer: D
Rationale: Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. Tachycardia primarily decreases diastole; systolic time changes very little. Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. Decreased O2 supply due to decreased time for filling of the coronary arteries increases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling.