NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis?
Correct Answer: B
Rationale: Station refers to the relationship of the presenting part to the ischial spines. A station of -1 indicates the fetal head is 1 cm above the ischial spines.
Question 2 of 5
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
Question 3 of 5
A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:
Correct Answer: A
Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.
Question 4 of 5
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
Correct Answer: A
Rationale: Nosebleeds in preeclampsia may indicate severe hypertension or coagulopathy, requiring immediate reporting. Pedal edema is common, bed rest is not always needed, and sodium restriction is secondary.
Question 5 of 5
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.