NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of preeclampsia. The nurse should monitor for which complication?
Correct Answer: A
Rationale: Preeclampsia can progress to eclampsia characterized by seizures a life-threatening complication. Premature rupture of membranes macrosomia and hypoglycemia are not directly related to preeclampsia.
Question 2 of 5
The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being.
Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
Question 3 of 5
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (
B), oral care (
C), and breathing exercises (
D) are supportive but less critical for ICP control.
Question 4 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 5 of 5
The client is admitted with a diagnosis of molar pregnancy. Which nursing intervention is most appropriate?
Correct Answer: A
Rationale: Molar pregnancy involves abnormal trophoblastic tissue not a viable fetus and can cause significant vaginal bleeding. Monitoring for bleeding is the most appropriate intervention. Cesarean delivery tocolytics and fetal monitoring are not indicated.