NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected rheumatoid arthritis. Which finding is most characteristic of this condition?
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis, reflecting synovial inflammation. Joint pain is symmetrical, fever and weight loss are less specific, and nodules are subcutaneous, not spinal.
Question 2 of 5
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level, drawn two hours ago, is 30 mcg/mL. What is the appropriate nursing action?
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is toxic (therapeutic range: 10–20 mcg/mL). Holding the dose and notifying the physician prevents toxicity. Administering (
A), decreasing (
C), or increasing (
D) the dose without physician input is unsafe.
Question 3 of 5
Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:
Correct Answer: A
Rationale: Any movement of the affected limb will cause discomfort to the child, so careful handling is essential during the acute phase.
Question 4 of 5
The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
Correct Answer: A
Rationale: Tachycardia is a hallmark of hypovolemic shock, compensating for reduced blood volume. Hypothermia (
B) is secondary, bradypnea (
C) is atypical, and hypertension (
D) is not associated.
Question 5 of 5
A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately:
Correct Answer: C
Rationale: At 10 weeks, the fundus is located slightly above the symphysis pubis. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located approximately at the umbilicus. At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.