NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30 bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165-175 bpm with variability of 0-2 bpm. What is the most likely explanation of this pattern?
Correct Answer: D
Rationale: Late decelerations (FHR drop at contraction peak) with minimal variability suggest uteroplacental insufficiency, impairing fetal oxygenation.
Question 2 of 5
After a traumatic accident, the client must have his left arm amputated in an emergency procedure. When the client wakes from anesthesia and sees his arm has been amputated, he becomes extremely distressed. He cries uncontrollably and yells about how angry he is at the doctor. The best therapeutic action from the nurse is
Correct Answer: B
Rationale: Sitting quietly with the client provides emotional support, allowing him to process grief and anger without judgment.
Question 3 of 5
The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?
Correct Answer: C
Rationale: Daily measurement of abdominal girth is the most sensitive method to detect early ascites by tracking subtle increases in abdominal size.
Question 4 of 5
The nurse is preparing to administer digoxin (Lanoxin) 0.25 mg IV to a client with heart failure. Prior to administration, the nurse checks the client’s apical pulse and finds it to be 52 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as it can exacerbate bradycardia
Question 5 of 5
A client is to wear a Holter monitor for continuous cardiac monitoring for 48 hours. The nurse should advise the client to avoid which of the following activities during the monitoring period? Select all that apply.
Correct Answer: C,D
Rationale: Holter monitors can be affected by electromagnetic interference from wireless devices like iPads (
C), so these should be avoided. Showering and bathing (
D) can damage the monitor or electrodes. Watching TV (
A), using a remote control (
B), drinking caffeine (E), and exercising (F) typically do not interfere with monitoring, though exercise should be noted in the activity log.