NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
Nursing assessment of early evidence of septic shock in children at risk includes:
Correct Answer: A
Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.
Question 2 of 5
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
Question 3 of 5
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.
Question 4 of 5
A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
Correct Answer: A
Rationale: The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. Rubella infection during the second trimester may result in permanent hearing loss for the fetus. RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
Question 5 of 5
Before administering eardrops to a toddler,the nurse should recognize that it is essential to consider which of the following?
Correct Answer: C
Rationale: The toddler’s developmental level affects cooperation and ability to follow instructions during eardrop administration. Age is a factor but less specific and weight or understanding are secondary to developmental considerations.