NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.
Question 2 of 5
Which of the following electrolyte imbalances is likely to result in a shortened QT interval?
Correct Answer: A
Rationale: Hypercalcemia shortens the QT interval on an ECG by accelerating cardiac repolarization. Hyponatremia hypomagnesemia and hyperphosphatemia are more likely to prolong the QT interval or have other ECG effects.
Question 3 of 5
A client with a history of a peptic ulcer is receiving Zantac (ranitidine). The nurse should teach the client to:
Correct Answer: B
Rationale: Caffeine can exacerbate peptic ulcers by increasing gastric acid production, counteracting ranitidine’s effects. Ranitidine is taken regardless of meals, and chest pain or fluids are secondary.
Question 4 of 5
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
Question 5 of 5
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.