NCLEX-RN
NCLEX RN Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
Correct Answer: D
Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.
Question 2 of 5
The nurse is caring for a client with a history of liver cirrhosis who is admitted with ascites. Which of the following interventions should the nurse implement?
Correct Answer: B
Rationale: furosemide is a diuretic used to reduce ascites in liver cirrhosis
Question 3 of 5
A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
Correct Answer: B
Rationale: Fetal heart tones are a definitive, objective sign of pregnancy, detectable around 20 weeks.
Question 4 of 5
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:
Correct Answer: C
Rationale: An L/S ratio of 1:1 indicates immature fetal lungs, increasing the risk of respiratory distress syndrome, despite the presence of phosphatidylglycerol.
Question 5 of 5
A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
Correct Answer: C
Rationale: Air embolism requires placing the client in the left lateral decubitus position with the head down to trap air in the right atrium, preventing further embolization. This is the priority action.