NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 2 of 5
The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
Correct Answer: C
Rationale: Head measurement (e.g., head circumference) is the most objective for hydrocephalus, directly assessing skull enlargement. Anorexia (
A), vomiting (
B), and temperature (
D) are subjective or less specific.
Question 3 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 4 of 5
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
Correct Answer: A
Rationale: This answer is correct. If the cause is removed, the delirious client will recover completely. This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
Question 5 of 5
Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
Correct Answer: C
Rationale: Pieces of cereal are soft, small, and safe for a toddler to chew, promoting jaw development without posing a choking hazard, unlike hot dogs, carrot sticks, or raisins.