NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
Correct Answer: C
Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.
Question 2 of 5
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
Correct Answer: D
Rationale: Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
Question 3 of 5
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
Correct Answer: A
Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
Question 4 of 5
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
Correct Answer: D
Rationale: This goal is not the most important. There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. Ipecac is not used for caustic alkali and acid ingestions. Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
Question 5 of 5
The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?
Correct Answer: B
Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.