NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
Question 2 of 5
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
Question 3 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.
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
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.