NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 2 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.
Question 3 of 5
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
Correct Answer: B
Rationale: This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. Sexual infantilism is characteristic of this syndrome. Gynecomastia is a symptom in Klinefelter's syndrome.
Question 4 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.
Question 5 of 5
The nurse is caring for a client with a history of a mastectomy who is receiving Tamoxifen (Nolvadex). The nurse should teach the client to:
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, so vaginal bleeding must be reported immediately. Sun exposure, caffeine, and fluid intake are not primary concerns.