NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected dehydration. Which finding is most indicative?
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.
Question 2 of 5
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
Correct Answer: C
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client (e.g. to the left side) can relieve pressure on the cord and improve fetal oxygenation. Notifying the doctor or starting an IV are secondary if repositioning resolves the issue.
Question 3 of 5
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
Correct Answer: C
Rationale: (
Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.
Question 4 of 5
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:
Correct Answer: D
Rationale: Overeating can lead to obesity, but not to edema. There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
Question 5 of 5
The nurse is caring for a client with a history of a tracheoesophageal fistula. The nurse should:
Correct Answer: D
Rationale: A tracheoesophageal fistula risks aspiration, requiring restricted oral intake until surgically repaired. Positioning, suctioning, and feedings are secondary or contraindicated.