NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose 'just 5 more lb.' Her symptoms are consistent with:
Correct Answer: D
Rationale: All symptoms and vital signs are consistent with anorexia nervosa.
Question 2 of 5
A client is being monitored using a central venous pressure monitor. If the CVP is 1 cm of water, the nurse should:
Correct Answer: A
Rationale: A CVP of 1 cm of water (normal range 2–8 mmHg or 3–10 cm H2O) is low, suggesting hypovolemia or decreased venous return. The nurse should notify the physician immediately for further evaluation and possible fluid administration.
Question 3 of 5
A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her:
Correct Answer: C
Rationale: This nursing action may cause hyperventilation. This nursing action could cause inferior vena cava syndrome. The client is allowed to push only after complete dilation during the second stage of labor. The nurse needs to know the stages of labor. If the client pushes before dilation, it could cause cervical edema and/or edema to the fetal scalp; both of these could contribute to increased risk of complications.
Question 4 of 5
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
Correct Answer: C
Rationale: The ABCs of trauma care prioritize airway establishment, followed by controlling hemorrhage and preventing shock, then assessing head injuries to ensure oxygenation and perfusion.
Question 5 of 5
The nurse is teaching a client with peritoneal dialysis how to manage exchanges at home. The nurse should tell the client to notify the doctor immediately if:
Correct Answer: A
Rationale: Cloudy dialysate returns suggest peritonitis, a serious complication of peritoneal dialysis, requiring immediate medical attention.