NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
Question 2 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
Correct Answer: A
Rationale: Postpartum endometritis is treated with antibiotics to address the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
Question 3 of 5
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
Question 4 of 5
A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:
Correct Answer: A
Rationale: It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it.
Question 5 of 5
The client is prescribed alendronate (Fosamax) for osteoporosis. Which instruction should the nurse include?
Correct Answer: A
Rationale: Alendronate should be taken with a full glass of water on an empty stomach, and the client should remain upright for 30 minutes to prevent esophageal irritation. Meals and lying down reduce absorption.