Questions 150

NCLEX-RN

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NCLEX RN Questions with Detailed Explanations Questions

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Question 1 of 5

As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

Correct Answer: D

Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.

Question 2 of 5

A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.

Question 3 of 5

Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?

Correct Answer: A

Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.

Question 4 of 5

A client with a history of depression is prescribed sertraline (Zoloft). The nurse should teach the client to report which side effect?

Correct Answer: C

Rationale: Suicidal thoughts are a serious side effect of SSRIs like sertraline, especially in the early weeks, requiring immediate reporting to ensure client safety.

Question 5 of 5

A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?

Correct Answer: C

Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.

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To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
The nurse is caring for a client who has just returned to the nursing unit after an intravenous pyelogram (IVP). Which of the following nursing interventions is most appropriate at this time?
The nurse is caring for a client with a history of multiple sclerosis. Which of the following interventions should be included in the plan of care?

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