NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of pericarditis. Which assessment finding is most characteristic?
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by sitting forward, reducing pressure on the inflamed pericardium. Bradycardia, edema, and muffled sounds are less specific or indicate complications like tamponade.
Question 2 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 3 of 5
The therapeutic blood-level range for lithium is:
Correct Answer: B
Rationale: This range is too low to be therapeutic. This is the therapeutic range for lithium. This range is above the therapeutic level. This range is toxic and may cause severe side effects.
Question 4 of 5
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
Correct Answer: D
Rationale: A full bladder is the most common cause of uterine displacement; having the client void addresses this before further interventions.
Question 5 of 5
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:
Correct Answer: D
Rationale: When diabetic ketoacidosis exists, intracellular dehydration occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L.