NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:
Correct Answer: D
Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.
Question 2 of 5
A client with a history of a stroke is being taught to use a quad cane. The nurse should teach the client to:
Correct Answer: C
Rationale: The quad cane should be used on the weak side to support the affected leg post-stroke, improving balance. Holding in the strong hand or advancing with the strong leg is incorrect.
Question 3 of 5
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.
Question 4 of 5
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
Question 5 of 5
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?
Correct Answer: D
Rationale: Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.