NCLEX Questions, NCLEX RN Free Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Extract:


Question 1 of 5

A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:

Correct Answer: C

Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.

Question 2 of 5

A client with a history of a ventricular tachycardia is receiving Amiodarone (Cordarone). The nurse should monitor the client for:

Correct Answer: D

Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring monitoring for cough or dyspnea. Hypotension is possible but less specific, and hyperglycemia/hypokalemia are unrelated.

Question 3 of 5

The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?

Correct Answer: A

Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (
B), oral care (
C), and breathing exercises (
D) are supportive but less critical for ICP control.

Question 4 of 5

The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?

Correct Answer: A

Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being.
Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.

Question 5 of 5

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Correct Answer: C

Rationale: Edema and neck vein distention in a bronchitis client suggest right heart failure or cor pulmonale, requiring immediate assessment. Emphysema discharge (
A), antibiotics (
B), and abnormal PO2 (
D) are less urgent.

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