NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The client with a cervical dilation of 8cm suddenly becomes short of breath,cyanotic and hypotensive. The nurse should suspect which of the following complications?
Correct Answer: A
Rationale: Amniotic fluid embolus is a rare but life-threatening complication characterized by sudden dyspnea cyanosis and hypotension due to amniotic fluid entering the maternal circulation. These symptoms are not typical of transition phase abruption or cord prolapse.
Question 2 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.
Question 3 of 5
The primary cause of anemia in a client with chronic renal failure is:
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production, impairing red blood cell production and causing anemia. Iron absorption, RBC destruction, and intrinsic factor are secondary or unrelated.
Question 4 of 5
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
Correct Answer: D
Rationale: Weighing a child with nephrosis is to assess for edema, not nutrition. (B,
C) This is not the purpose for weighing the child. Weight and measurement are the primary ways of evaluating edema and fluid shifts.
Question 5 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.