NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is assessing the vital signs of a client with pancreatic cancer. In addition to routine vital signs, the nurse assesses the fifth vital sign of:
Correct Answer: B
Rationale: Pain is considered the fifth vital sign, alongside temperature, pulse, respiration, and blood pressure. It is routinely assessed, especially in conditions like pancreatic cancer, which often causes significant pain due to tumor invasion or obstruction.
Question 2 of 5
The nurse is performing an admission assessment on a client with a history of glaucoma. Which medication is the client most likely taking?
Correct Answer: B
Rationale: Timolol, a beta-blocker eye drop, is commonly used to reduce intraocular pressure in glaucoma. Lasix, Norvasc, and Zestril treat other conditions (edema, hypertension).
Question 3 of 5
The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:
Correct Answer: A
Rationale: Oxytocin is used to induce labor by stimulating uterine contractions in a term pregnancy.
Question 4 of 5
The nurse is caring for a client with a history of bipolar disorder. The nurse should give priority to:
Correct Answer: A
Rationale: Monitoring mood stability is critical in bipolar disorder to assess for manic or depressive episodes.
Question 5 of 5
A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
Correct Answer: A
Rationale: Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. Ice packs are appropriate to apply in the first 12 hours post-delivery to produce vasoconstriction and to reduce edema to the area.