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 ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 3 of 5
A client with a history of a colostomy is being discharged. The nurse should teach the client to:
Correct Answer: B
Rationale: High-fiber foods can cause blockages or excessive output in a colostomy. Bag changes depend on output, alcohol irritates the stoma, and irrigation is not always required.
Question 4 of 5
The client is admitted with a diagnosis of ectopic pregnancy. Which symptom is most characteristic of this condition?
Correct Answer: A
Rationale: Ectopic pregnancy often presents with sudden sharp abdominal pain due to tubal stretching or rupture. Painless bleeding is more typical of placenta previa and fever or edema are not characteristic.
Question 5 of 5
A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:
Correct Answer: A
Rationale: This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. This answer is incorrect. The client should continue the medication until the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.