NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
Early in her ninth month of pregnancy, a client has been diagnosed as having mild preeclampsia. In counseling her about her diet, the nurse must emphasize the importance of:
Correct Answer: D
Rationale: Women with pregnancy-induced hypertension have a reduced plasma volume secondary to venous vessel constriction, not hypovolemia; therefore, sodium restriction is not recommended. It is suggested that these women avoid extremely salty foods. Drinking six to eight glasses of water per day facilitates optimal fluid volume and renal perfusion, but it will not decrease the venous vessel constriction of pregnancy-induced hypertension. Carbohydrate needs increase during pregnancy, specifically during the second and third trimesters, but they have not been linked to pregnancy-induced hypertension. Loss of urinary protein (proteinuria) is associated with increased permeability of the large protein molecules with pregnancy-induced hypertension. Additional dietary protein also helps increase the plasma colloidal osmotic pressure. Diets deficient in protein have been linked to pregnancy-induced hypertension.
Question 2 of 5
The client is admitted with a diagnosis of gestational trophoblastic disease. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Gestational trophoblastic disease (e.g. molar pregnancy) causes markedly elevated hCG levels due to abnormal trophoblastic proliferation. Fetal heart tones are absent uterine size is larger and hypotension is not typical.
Question 3 of 5
A client has an order to administer cisplatin (Platinol). Which drug would the nurse expect to be ordered to reduce renal toxicity from the cisplatin infusion?
Correct Answer: A
Rationale: Amifostine protects kidneys from cisplatin’s nephrotoxicity by neutralizing free radicals. Dexrazoxane (
B) protects the heart, Mesna (
C) prevents bladder toxicity, and Pamidronate (
D) treats hypercalcemia.
Question 4 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 5 of 5
A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. What do these clinical manifestations indicate to the nurse?
Correct Answer: B
Rationale: Shortness of breath, pleuritic pain, and hemoptysis are classic signs of pulmonary embolus, often associated with immobility from a fracture. CHF (
A) causes edema, ARDS (
C) causes diffuse respiratory failure, and tension pneumothorax (
D) causes tracheal deviation.