NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.
Question 2 of 5
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
Question 3 of 5
A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is:
Correct Answer: B
Rationale: Respondeat superior is Latin for 'The master is responsible for the acts of his servant'. The nurse, as an employee of the hospital, acted according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence, or tort law. (CN: Management of care; CL: Evaluate)
Question 4 of 5
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
Question 5 of 5
The 2nd priority needs according to the MAAUAR method of priority setting include which of the following?
Correct Answer: D
Rationale: The MAAUAR method prioritizes: Mental status, Acute pain, Acute eliminated needs, Urgent needs, Abnormal vital signs, Risks. The second priority is Acute pain, but among the options, Risks aligns as a high-priority need following initial physiological concerns.