NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the client with metabolic alkalosis. Which findings would likely be observed in this client?
Correct Answer: B, C, E, F
Rationale: Metabolic alkalosis results from excess bicarbonate or loss of acids (e.g., from vomiting). Vomiting and nausea (
C) are common causes. Numbness (
B), circumoral paresthesia (E), and hypertonic muscle contractions (F) occur due to hypocalcemia from alkalosis. Kussmaul’s respirations (
A) are associated with metabolic acidosis, and warm flushed skin (
D) is unrelated.
Question 2 of 5
At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?
Correct Answer: C
Rationale: At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
Question 3 of 5
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
Correct Answer: C
Rationale: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
Question 4 of 5
The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:
Correct Answer: B
Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.
Question 5 of 5
A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention?
Correct Answer: C
Rationale: A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. Epinephrine decreased inspiratory difficulty by stimulating α-, β1, and β2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). The person with asthma fights to inspire sufficient air thus increasing respiratory rate.