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
The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse expects to find the sputum to be:
Correct Answer: B
Rationale: Bright red sputum with streaks is associated with pneumonia caused by gram-negative bacteria, such as Klebsiella pneumonia. Pneumococcal pneumonia, caused by gram-positive bacteria, has a characteristic productive cough with green or rust-colored sputum. Green-colored sputum is more characteristic of Pseudomonas than of gram-positive bacterial pneumonia. Pink-tinged and frothy sputum is more characteristic of pulmonary edema than of gram-positive bacterial pneumonia.
Question 3 of 5
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age (macrosomic) due to maternal hyperglycemia and are at risk for hypoglycemia after birth due to high insulin levels. Hyperglycemia and small size are less common.
Question 4 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 5 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.