NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of abruptio placenta. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Abruptio placenta causes maternal tachycardia and hypotension (from bleeding) and fetal bradycardia (from hypoxia). All vital sign changes are likely in this condition.
Question 2 of 5
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
Correct Answer: A
Rationale: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.
Question 3 of 5
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
Question 4 of 5
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.
Question 5 of 5
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
Correct Answer: C
Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.