NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse suspects hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock?
Correct Answer: A, B, D
Rationale: Hypovolemic shock involves low blood volume, reflected by low hemoglobin (5 g,
A), low central venous pressure (2 mmHg,
B), and low hematocrit (22%,
D). Normal pulmonary artery wedge pressure (16 mmHg,
C) suggests no left heart failure. Elevated troponin (E) indicates myocardial damage, not volume status.
Question 2 of 5
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, a common complication, so monitoring for anemia is the priority.
Question 3 of 5
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.
Question 4 of 5
The nurse is caring for a client with a diagnosis of rheumatoid arthritis who is receiving methotrexate. Which laboratory value would be most concerning?
Correct Answer: A
Rationale: Methotrexate can cause bone marrow suppression. A WBC of 4,000/mm3 (
A) indicates leukopenia, increasing infection risk, and is most concerning. Platelets (
B), hemoglobin (
C), and creatinine (
D) are within normal limits.
Question 5 of 5
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
Correct Answer: A
Rationale: This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. The client's values are below levels for physiological anemia. The client is fatigued because of a low hemoglobin level. Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.