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
A 16-year-old client reports a weight loss of 20% of her previous weight. She has a history of food binges followed by self-induced vomiting (purging). The nurse should suspect a diagnosis of:
Correct Answer: C
Rationale: Bulimia is characterized by binge eating followed by purging, such as self-induced vomiting, leading to significant weight loss.
Question 3 of 5
Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application?
Correct Answer: D
Rationale: Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application, especially with fractures near the elbow.
Question 4 of 5
A child is to receive heparin sodium five units per kilogram of body weight by subcutaneous route every four hours. The child weighs 52.8 lb. How many units should the child receive in a 24 hour period?
Correct Answer: 720
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units/dose. Frequency: every 4 hours = 6 doses/day.
Total: 120 × 6 = 720 units.
Question 5 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.