NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?
Correct Answer: A
Rationale: Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. This action is of lesser importance at this time. Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. Once the victim enters the emergency room, it is important not to leave her alone.
Question 2 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 3 of 5
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
Correct Answer: A
Rationale: Increased locomotive skills make push-pull toys appropriate for the energetic toddler. Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. At age 8 months, infants begin to have pincer grasp.
Toys that help infants develop the pincer grasp are recommended for this age group. Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
Question 4 of 5
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
Question 5 of 5
The nurse is assessing an adult female client for hypovolemia.
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (
B) and BUN (
D) are within normal ranges, and urine specific gravity (
C) is normal, not elevated as expected in hypovolemia.