NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A vaginal exam reveals that the cervix is 4cm dilated,with intact membranes and a fetal heart tone rate of 160-170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
Correct Answer: B
Rationale: External fetal monitoring is appropriate when membranes are intact as internal monitoring requires ruptured membranes. The cervix is not closed fetal heart tones are normal and contraction intensity is irrelevant to external monitoring.
Question 2 of 5
A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:
Correct Answer: C
Rationale: Using Nägele's rule, subtract 3 months and add 7 days from January 15, resulting in October 22.
Question 3 of 5
During a change of shift, the oncoming nurse notes a discrepancy in the narcotic count. The nurse’s first action should be to:
Correct Answer: B
Rationale: A discrepancy in the narcotic count requires immediate investigation to ensure patient safety and compliance. Notifying the nursing supervisor is the first step, as they can initiate an internal review. The pharmacist, board, or director are notified later if needed.
Question 4 of 5
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
Correct Answer: A
Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.
Question 5 of 5
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
Correct Answer: B
Rationale: Blood pressure can remain normotensive in a state of hypovolemia. Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. Skin turgor is not a reliable indicator for assessing hydration in a burn client. Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.