NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
Question 2 of 5
A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.
Question 3 of 5
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.
Question 4 of 5
Allopurinol (Zyloprim) is prescribed for a client who has chronic gout. Which of the following comments indicates that the client understands how to take the allopurinol?
Correct Answer: C
Rationale: Drinking plenty of fluids prevents uric acid crystal formation, enhancing allopurinol's effectiveness in managing gout.
Question 5 of 5
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
Correct Answer: B
Rationale: Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.