NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
Correct Answer: A
Rationale: Abdominal assessment follows the sequence: inspection, auscultation, palpation. Auscultation is done before palpation to avoid altering bowel sounds. Inspection identifies visible abnormalities first.
Question 2 of 5
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
Correct Answer: B
Rationale: Meperidine given close to delivery can cause neonatal respiratory depression due to its sedative effects crossing the placenta. The nurse should question the timing of the order.
Question 3 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
Question 4 of 5
A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. What do these clinical manifestations indicate to the nurse?
Correct Answer: B
Rationale: Shortness of breath, pleuritic pain, and hemoptysis are classic signs of pulmonary embolus, often associated with immobility from a fracture. CHF (
A) causes edema, ARDS (
C) causes diffuse respiratory failure, and tension pneumothorax (
D) causes tracheal deviation.
Question 5 of 5
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
Correct Answer: C
Rationale: G=3 (current pregnancy), T=1 (term birth), P=1 (preterm birth), A=0 (no abortions), L=2 (living children).