NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of septic shock. Which intervention is the priority?
Correct Answer: A
Rationale: In septic shock, administering IV antibiotics within the first hour is the priority to target the infection causing shock. Vasopressors, catheterization, and cultures are secondary.
Question 2 of 5
The amniocentesis reveals that the patient has a high AFP level. The nurse is aware that a high level of AFP is associated with which of the following?
Correct Answer: A
Rationale: High alpha-fetoprotein (AFP) levels in amniotic fluid are associated with neural tube defects such as myelomeningocele (a type of spina bifida). Esophageal atresia omphalocele and Trisomy 21 (Down syndrome) are not typically associated with elevated AFP levels.
Question 3 of 5
A female client with major depression stated that 'life is hopeless and not worth living.' The nurse should place highest priority on which of the following questions?
Correct Answer: B
Rationale: Maintenance of the client's life is the priority; assessment of suicidal intent is imperative.
Question 4 of 5
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
Correct Answer: A
Rationale: Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto-Bismol is also classified as a salicylate and should be avoided. Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. Although viral pneumonia can be a complication of influenza, this would not be an initial priority.
Question 5 of 5
A client with a history of rheumatoid arthritis is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in rheumatoid arthritis may indicate anemia of chronic disease, so monitoring for anemia is the priority.